DEEL 5
Inleiding: autacoïden bij inflammatie en allergie ........................................................................................6
1. Niet-steroïdale anti-inflammatoire geneesmiddelen .............................................................................7
1.1 Chemie van NSAIDs ...........................................................................................................................7
1.2 Werkingsmechanisme van NSAIDs ....................................................................................................7
1.3 Farmacokinetiek van NSAIDs .............................................................................................................8
1.4 Farmacodynamiek van NSAIDs ..........................................................................................................8
1.5 Indicaties ............................................................................................................................................8
1.6 Bijwerkingen ......................................................................................................................................9
Gastro-intestinaal ................................................................................................................................9
Bloedplaatjes .......................................................................................................................................9
Renaal en cardiovasculair ....................................................................................................................9
Overgevoeligheidsreacties ..................................................................................................................9
Hepatotoxiciteit en hematologische toxiciteit....................................................................................9
1.7 Contra-indicaties en risicopopulaties ..............................................................................................10
1.8 Interacties ........................................................................................................................................10
1.9 Kiezen van een NSAID ......................................................................................................................10
1.10 Bespreking van de individuele groepen NSAIDs ...........................................................................10
A. Salicylaten ......................................................................................................................................10
B. Para-aminofenol derivaten ...........................................................................................................12
C. Indool- en arylazijnzuurderivaten .................................................................................................13
D. Arylpropionzuurderivaten .............................................................................................................13
E. Oxicams ..........................................................................................................................................13
F. Pyrazolonderivaten ........................................................................................................................14
G. Selectieve COX2 inhibitoren (coxibs) ............................................................................................14
Besluit ....................................................................................................................................................14
2. Glucocorticoiden....................................................................................................................................15
2.1 Producten: chemie van glucocorticoiden .......................................................................................15
2.2 Werkingsmechanisme .....................................................................................................................15
2.3 Farmacokinetiek ..............................................................................................................................16
2.4 Farmacodynamiek ...........................................................................................................................16
2.5 Indicaties ..........................................................................................................................................17
2.6 Bijwerkingen ....................................................................................................................................17
Metabole effecten .............................................................................................................................17
1
, Feedback effecten .............................................................................................................................18
Effecten op mesemchymale cellen ...................................................................................................18
Anti-inflammatoire en immunosuppressief effect ...........................................................................19
Effecten in het CZS ............................................................................................................................19
Andere bijwerkingen .........................................................................................................................19
2.7 Risicopopulaties ...............................................................................................................................19
3. Tweedelijns anti-reumatische geneesmiddelen ...................................................................................20
3.1 Disease modifying antirheumatic drugs (DMARDs) ........................................................................20
Conventionele synthetische small molecule DMARDs (csDMARDs) ................................................20
Biological DMARDs (bDMARDs) ........................................................................................................21
Targeted synthetic DMARDs (tsDMARDs).........................................................................................22
3.2 Andere immunomodulatoren .........................................................................................................22
Ciclosporine .......................................................................................................................................22
Tacrolimus, sirolimus en derivaten ...................................................................................................23
Azathioprine ......................................................................................................................................23
Mycofenolaatmofetil .........................................................................................................................23
Monoklonale antistoffen ...................................................................................................................23
4. Farmacotherapie van migraine .............................................................................................................24
4.1 Medicijnen om een aanval te couperen .........................................................................................24
Niet-specifieke anti-migraine geneesmiddelen ................................................................................24
Specifieke anti-migraine geneesmiddelen ........................................................................................24
5. Farmacotherapie van jicht .....................................................................................................................26
Inleiding .................................................................................................................................................26
5.1 NSAIDs..............................................................................................................................................26
5.2 Colchicine .........................................................................................................................................26
5.3 Glucocorticoïden .............................................................................................................................27
5.4 Uricostatica: allopurinol en febuxostat ...........................................................................................27
5.5 Uricosurica: probenecid (organisch zuur) en lesinurad ..................................................................28
5.6 Recombinant uraat oxidase.............................................................................................................28
5.7 Canakinumab ...................................................................................................................................28
Verbeter je inzicht .................................................................................................................................28
6. Farmacotherapie van hooikoorts, uticaria en angio-oedeem: antihistaminica ...................................29
Inleiding .................................................................................................................................................29
Farmacologische effecten .................................................................................................................29
6.1 H1-receptorantagonisten .................................................................................................................30
Eigenschappen, chemie en werkingsmechanisme ...........................................................................30
2
, Farmacokinetiek ................................................................................................................................31
Farmacodynamiek .............................................................................................................................31
Indicaties ............................................................................................................................................31
Relatieve contra-indicaties ................................................................................................................32
Bijwerkingen ......................................................................................................................................32
Interacties ..........................................................................................................................................32
Behandeling van seizoensgebonden allergische rhino-conjunctivitis ..............................................32
7. Farmacotherapie van astma ..................................................................................................................33
7.1 Inleiding ...........................................................................................................................................33
7.2 Anti-astmageneesmiddelen ............................................................................................................33
Kortwerkende beta-2 mimetica ........................................................................................................33
Langwerkende beta-2 mimetica .......................................................................................................34
Corticosteroïden ................................................................................................................................34
Theofylline .........................................................................................................................................35
Anticholinergica .................................................................................................................................36
Leukotrieenreceptor-antagonisten ...................................................................................................36
Andere geneesmiddelen ...................................................................................................................37
Aandachtspunten ..............................................................................................................................37
Inhalatiesystemen .............................................................................................................................37
8. Farmacotherapie van anafylactische reacties .......................................................................................38
Verbeter je inzicht .................................................................................................................................39
9. Farmacotherapie van diabetes mellitus ................................................................................................40
9.1 Insuline en analogen........................................................................................................................40
Structuur, vrijstelling, werking en effecten.......................................................................................40
Farmacokinetiek ................................................................................................................................41
Indicaties ............................................................................................................................................41
Bijwerkingen ......................................................................................................................................41
9.2 Orale antidiabetica ..........................................................................................................................42
Biguaniden .........................................................................................................................................42
Sulfonylureumderivaten of sulfamiden ............................................................................................42
Gliniden ..............................................................................................................................................43
Thiazolidinedionen of glitazonen ......................................................................................................43
Alfa-glucosidase inhibitoren ..............................................................................................................44
Gliptinen ............................................................................................................................................44
Gliflozinen (SGLT2 inhibitoren) .........................................................................................................44
9.3 Incretinemimetica ....................................................................................................................45
3
,10. Farmacotherapie en preventie van osteoporose ...............................................................................46
10.1 Inleiding .........................................................................................................................................46
10.2 Calcium ..........................................................................................................................................47
10.3 Vitamine D .....................................................................................................................................47
10.4 Bifosfonaten ..................................................................................................................................48
10.5 Selectieve oestrogeenreceptor-modulatoren (SERMs) ................................................................49
10.6 Teriparatide ...................................................................................................................................49
10.7 Denosumab....................................................................................................................................50
11. Farmacotherapie van kanker...............................................................................................................51
11.2 Algemeen .......................................................................................................................................51
Eigenschappen van maligne cellen ...................................................................................................51
11.3 Principes in de kankerchemotherapie ..........................................................................................51
Terminologie ......................................................................................................................................52
Nevenwerkingen/toxiciteit op kankertherapie .................................................................................52
1.4 Stoffen..............................................................................................................................................52
Cytotoxische toffen ...........................................................................................................................52
Hormonale stoffen ............................................................................................................................53
Immuuntherapie ................................................................................................................................54
Proteïnekinase inhibitoren ................................................................................................................55
12. Supportieve behandeling bij kanker....................................................................................................56
13. Famacologische aspecten in palliatieve en terminale zorg ................................................................57
13.2 Symptoomcontrole in de palliatieve zorg .....................................................................................57
Pijn .....................................................................................................................................................57
Gastro-intestinale problemen ...........................................................................................................58
Respiratoire problemen ....................................................................................................................59
Neurologische problemen .................................................................................................................60
13.3 Medicatietoedieningsroutes .........................................................................................................61
14. Farmacotherapie van het gastrointestinaal stelsel .............................................................................62
14.1 Farmacotherapie van peptische aandoeningen: ulcera en GERD ................................................62
H2-receptorantagonisten ..................................................................................................................62
Protonpompinhibitoren ....................................................................................................................63
Misoprostol ........................................................................................................................................63
Antacida .............................................................................................................................................64
Antibiotica ..........................................................................................................................................64
14.2 (Gastro)-prokinetica ......................................................................................................................64
Dopamine-2-receptorantagonisten ..................................................................................................64
4
, Cisapride ............................................................................................................................................65
14.3 Anti-emetica ..................................................................................................................................65
14.4 Pancreasenzym-substituut ............................................................................................................65
14.5 Laxantia ..........................................................................................................................................66
14.6 Anti-diarrheïca ...............................................................................................................................66
14.7 Farmaca bij inflammatoir darmlijden ......................................................................................66
14.8 Behandeling van infestatie met wormen ......................................................................................67
Addendum 1: geneesmiddelen en QT-verlenging ....................................................................................68
Addendum 2: casusbespreking ............................................................ Fout! Bladwijzer niet gedefinieerd.
5
, INLEIDING: AUTACOÏDEN BIJ INFLAMMATIE EN ALLERGIE
Autacoïden
• = endogene stoffen
• Rol in normale celhomeostase
• Rol bij weefselbeschadiging en ontstekingsreacties
o Oa prostanoïden (behoren tot de eicosanoïden)
• Rol bij allergische reacties
• Lokale hormonen, wnt korte halfwaardetijd
o -> autocriene effecten (effecten op cel waardoor ze worden afgescheiden)
o -> paracriene effecten (effecten op naburige cellen)
• Bevatten: neurotransmitters, peptiden, vetzuurderivaten en anorganische moleculen
6
, 1. NIET-STEROÏDALE ANTI-INFLAMMATOIRE GENEESMIDDELEN
• Meeste NSAIDs remmen COX1 en COX2 -> dus remmen synthese PGs en TXs
• - COX2 is waarschijnlijk de oorzaak van de beoogde analgestische, antipyretische en anti-
inflammatoire effecten
• - COX 1 is waarschijnlijk de oorzaak van de ongewenste effecten
• PG = prostaglandines
• LT = leukotreïnen
• TX = tromboxanen
1.1 CHEMIE VAN NSAIDS
• Heterogenen groep verbindingen (meestal zwakke zuren) met gemeenschappelijk
werkingsmechanisme
• Aspirine = prototype
• Onderscheid volgens chemische structuur
o Salicylaten: acetylsalicylzuur, sulfasalazine
o Para-aminofenol of anniline derivaten: paracetamol, fenacetine
o Indool- en arylazijnzuurderivaten: indometacine, diclofenac, aclefenac, ketorolac
o Arylpropionzuurderivaten: ibuprofen, naproxen
o Oxicams: meloxicam, piroxicam, tenoxicam
o Pyrazolonderivaten: metamizol, fenylbutazon
o COX-2 selectieve NSAIDs of Coxibs: celecoxib, etoricoxib, parecoxib
o Fenamaten of N-fenylanthranylzuurdervitane: mefenaminezuur, meclofenaminezuur
1.2 WERKINGSMECHANISME VAN NSAIDS
• Acetylsalicylzuur is enige NSAID dat covalent (irreversiebel) bindt aan COX1 en COX2
Andere binden reversibel
à inhibitie synthese prostanoïden (PGs en TXs)
à kan onrechtstreeks ook leiden tot verhoogde aanmaak van LT door grotere aanbod van
substraat aan enzyme lipoxygenase
• Goede correlatie tussen in vitro potentie en in vivo anti-inflammatoire activiteit
• Inhibitie niet selectief voor COX 1 of COX 2, maar toch verschillende gevoeligheid -> sommige
preferentieel COX-1 inhibitie, andere preferentieel COX-2 inhibitie
7
Inleiding: autacoïden bij inflammatie en allergie ........................................................................................6
1. Niet-steroïdale anti-inflammatoire geneesmiddelen .............................................................................7
1.1 Chemie van NSAIDs ...........................................................................................................................7
1.2 Werkingsmechanisme van NSAIDs ....................................................................................................7
1.3 Farmacokinetiek van NSAIDs .............................................................................................................8
1.4 Farmacodynamiek van NSAIDs ..........................................................................................................8
1.5 Indicaties ............................................................................................................................................8
1.6 Bijwerkingen ......................................................................................................................................9
Gastro-intestinaal ................................................................................................................................9
Bloedplaatjes .......................................................................................................................................9
Renaal en cardiovasculair ....................................................................................................................9
Overgevoeligheidsreacties ..................................................................................................................9
Hepatotoxiciteit en hematologische toxiciteit....................................................................................9
1.7 Contra-indicaties en risicopopulaties ..............................................................................................10
1.8 Interacties ........................................................................................................................................10
1.9 Kiezen van een NSAID ......................................................................................................................10
1.10 Bespreking van de individuele groepen NSAIDs ...........................................................................10
A. Salicylaten ......................................................................................................................................10
B. Para-aminofenol derivaten ...........................................................................................................12
C. Indool- en arylazijnzuurderivaten .................................................................................................13
D. Arylpropionzuurderivaten .............................................................................................................13
E. Oxicams ..........................................................................................................................................13
F. Pyrazolonderivaten ........................................................................................................................14
G. Selectieve COX2 inhibitoren (coxibs) ............................................................................................14
Besluit ....................................................................................................................................................14
2. Glucocorticoiden....................................................................................................................................15
2.1 Producten: chemie van glucocorticoiden .......................................................................................15
2.2 Werkingsmechanisme .....................................................................................................................15
2.3 Farmacokinetiek ..............................................................................................................................16
2.4 Farmacodynamiek ...........................................................................................................................16
2.5 Indicaties ..........................................................................................................................................17
2.6 Bijwerkingen ....................................................................................................................................17
Metabole effecten .............................................................................................................................17
1
, Feedback effecten .............................................................................................................................18
Effecten op mesemchymale cellen ...................................................................................................18
Anti-inflammatoire en immunosuppressief effect ...........................................................................19
Effecten in het CZS ............................................................................................................................19
Andere bijwerkingen .........................................................................................................................19
2.7 Risicopopulaties ...............................................................................................................................19
3. Tweedelijns anti-reumatische geneesmiddelen ...................................................................................20
3.1 Disease modifying antirheumatic drugs (DMARDs) ........................................................................20
Conventionele synthetische small molecule DMARDs (csDMARDs) ................................................20
Biological DMARDs (bDMARDs) ........................................................................................................21
Targeted synthetic DMARDs (tsDMARDs).........................................................................................22
3.2 Andere immunomodulatoren .........................................................................................................22
Ciclosporine .......................................................................................................................................22
Tacrolimus, sirolimus en derivaten ...................................................................................................23
Azathioprine ......................................................................................................................................23
Mycofenolaatmofetil .........................................................................................................................23
Monoklonale antistoffen ...................................................................................................................23
4. Farmacotherapie van migraine .............................................................................................................24
4.1 Medicijnen om een aanval te couperen .........................................................................................24
Niet-specifieke anti-migraine geneesmiddelen ................................................................................24
Specifieke anti-migraine geneesmiddelen ........................................................................................24
5. Farmacotherapie van jicht .....................................................................................................................26
Inleiding .................................................................................................................................................26
5.1 NSAIDs..............................................................................................................................................26
5.2 Colchicine .........................................................................................................................................26
5.3 Glucocorticoïden .............................................................................................................................27
5.4 Uricostatica: allopurinol en febuxostat ...........................................................................................27
5.5 Uricosurica: probenecid (organisch zuur) en lesinurad ..................................................................28
5.6 Recombinant uraat oxidase.............................................................................................................28
5.7 Canakinumab ...................................................................................................................................28
Verbeter je inzicht .................................................................................................................................28
6. Farmacotherapie van hooikoorts, uticaria en angio-oedeem: antihistaminica ...................................29
Inleiding .................................................................................................................................................29
Farmacologische effecten .................................................................................................................29
6.1 H1-receptorantagonisten .................................................................................................................30
Eigenschappen, chemie en werkingsmechanisme ...........................................................................30
2
, Farmacokinetiek ................................................................................................................................31
Farmacodynamiek .............................................................................................................................31
Indicaties ............................................................................................................................................31
Relatieve contra-indicaties ................................................................................................................32
Bijwerkingen ......................................................................................................................................32
Interacties ..........................................................................................................................................32
Behandeling van seizoensgebonden allergische rhino-conjunctivitis ..............................................32
7. Farmacotherapie van astma ..................................................................................................................33
7.1 Inleiding ...........................................................................................................................................33
7.2 Anti-astmageneesmiddelen ............................................................................................................33
Kortwerkende beta-2 mimetica ........................................................................................................33
Langwerkende beta-2 mimetica .......................................................................................................34
Corticosteroïden ................................................................................................................................34
Theofylline .........................................................................................................................................35
Anticholinergica .................................................................................................................................36
Leukotrieenreceptor-antagonisten ...................................................................................................36
Andere geneesmiddelen ...................................................................................................................37
Aandachtspunten ..............................................................................................................................37
Inhalatiesystemen .............................................................................................................................37
8. Farmacotherapie van anafylactische reacties .......................................................................................38
Verbeter je inzicht .................................................................................................................................39
9. Farmacotherapie van diabetes mellitus ................................................................................................40
9.1 Insuline en analogen........................................................................................................................40
Structuur, vrijstelling, werking en effecten.......................................................................................40
Farmacokinetiek ................................................................................................................................41
Indicaties ............................................................................................................................................41
Bijwerkingen ......................................................................................................................................41
9.2 Orale antidiabetica ..........................................................................................................................42
Biguaniden .........................................................................................................................................42
Sulfonylureumderivaten of sulfamiden ............................................................................................42
Gliniden ..............................................................................................................................................43
Thiazolidinedionen of glitazonen ......................................................................................................43
Alfa-glucosidase inhibitoren ..............................................................................................................44
Gliptinen ............................................................................................................................................44
Gliflozinen (SGLT2 inhibitoren) .........................................................................................................44
9.3 Incretinemimetica ....................................................................................................................45
3
,10. Farmacotherapie en preventie van osteoporose ...............................................................................46
10.1 Inleiding .........................................................................................................................................46
10.2 Calcium ..........................................................................................................................................47
10.3 Vitamine D .....................................................................................................................................47
10.4 Bifosfonaten ..................................................................................................................................48
10.5 Selectieve oestrogeenreceptor-modulatoren (SERMs) ................................................................49
10.6 Teriparatide ...................................................................................................................................49
10.7 Denosumab....................................................................................................................................50
11. Farmacotherapie van kanker...............................................................................................................51
11.2 Algemeen .......................................................................................................................................51
Eigenschappen van maligne cellen ...................................................................................................51
11.3 Principes in de kankerchemotherapie ..........................................................................................51
Terminologie ......................................................................................................................................52
Nevenwerkingen/toxiciteit op kankertherapie .................................................................................52
1.4 Stoffen..............................................................................................................................................52
Cytotoxische toffen ...........................................................................................................................52
Hormonale stoffen ............................................................................................................................53
Immuuntherapie ................................................................................................................................54
Proteïnekinase inhibitoren ................................................................................................................55
12. Supportieve behandeling bij kanker....................................................................................................56
13. Famacologische aspecten in palliatieve en terminale zorg ................................................................57
13.2 Symptoomcontrole in de palliatieve zorg .....................................................................................57
Pijn .....................................................................................................................................................57
Gastro-intestinale problemen ...........................................................................................................58
Respiratoire problemen ....................................................................................................................59
Neurologische problemen .................................................................................................................60
13.3 Medicatietoedieningsroutes .........................................................................................................61
14. Farmacotherapie van het gastrointestinaal stelsel .............................................................................62
14.1 Farmacotherapie van peptische aandoeningen: ulcera en GERD ................................................62
H2-receptorantagonisten ..................................................................................................................62
Protonpompinhibitoren ....................................................................................................................63
Misoprostol ........................................................................................................................................63
Antacida .............................................................................................................................................64
Antibiotica ..........................................................................................................................................64
14.2 (Gastro)-prokinetica ......................................................................................................................64
Dopamine-2-receptorantagonisten ..................................................................................................64
4
, Cisapride ............................................................................................................................................65
14.3 Anti-emetica ..................................................................................................................................65
14.4 Pancreasenzym-substituut ............................................................................................................65
14.5 Laxantia ..........................................................................................................................................66
14.6 Anti-diarrheïca ...............................................................................................................................66
14.7 Farmaca bij inflammatoir darmlijden ......................................................................................66
14.8 Behandeling van infestatie met wormen ......................................................................................67
Addendum 1: geneesmiddelen en QT-verlenging ....................................................................................68
Addendum 2: casusbespreking ............................................................ Fout! Bladwijzer niet gedefinieerd.
5
, INLEIDING: AUTACOÏDEN BIJ INFLAMMATIE EN ALLERGIE
Autacoïden
• = endogene stoffen
• Rol in normale celhomeostase
• Rol bij weefselbeschadiging en ontstekingsreacties
o Oa prostanoïden (behoren tot de eicosanoïden)
• Rol bij allergische reacties
• Lokale hormonen, wnt korte halfwaardetijd
o -> autocriene effecten (effecten op cel waardoor ze worden afgescheiden)
o -> paracriene effecten (effecten op naburige cellen)
• Bevatten: neurotransmitters, peptiden, vetzuurderivaten en anorganische moleculen
6
, 1. NIET-STEROÏDALE ANTI-INFLAMMATOIRE GENEESMIDDELEN
• Meeste NSAIDs remmen COX1 en COX2 -> dus remmen synthese PGs en TXs
• - COX2 is waarschijnlijk de oorzaak van de beoogde analgestische, antipyretische en anti-
inflammatoire effecten
• - COX 1 is waarschijnlijk de oorzaak van de ongewenste effecten
• PG = prostaglandines
• LT = leukotreïnen
• TX = tromboxanen
1.1 CHEMIE VAN NSAIDS
• Heterogenen groep verbindingen (meestal zwakke zuren) met gemeenschappelijk
werkingsmechanisme
• Aspirine = prototype
• Onderscheid volgens chemische structuur
o Salicylaten: acetylsalicylzuur, sulfasalazine
o Para-aminofenol of anniline derivaten: paracetamol, fenacetine
o Indool- en arylazijnzuurderivaten: indometacine, diclofenac, aclefenac, ketorolac
o Arylpropionzuurderivaten: ibuprofen, naproxen
o Oxicams: meloxicam, piroxicam, tenoxicam
o Pyrazolonderivaten: metamizol, fenylbutazon
o COX-2 selectieve NSAIDs of Coxibs: celecoxib, etoricoxib, parecoxib
o Fenamaten of N-fenylanthranylzuurdervitane: mefenaminezuur, meclofenaminezuur
1.2 WERKINGSMECHANISME VAN NSAIDS
• Acetylsalicylzuur is enige NSAID dat covalent (irreversiebel) bindt aan COX1 en COX2
Andere binden reversibel
à inhibitie synthese prostanoïden (PGs en TXs)
à kan onrechtstreeks ook leiden tot verhoogde aanmaak van LT door grotere aanbod van
substraat aan enzyme lipoxygenase
• Goede correlatie tussen in vitro potentie en in vivo anti-inflammatoire activiteit
• Inhibitie niet selectief voor COX 1 of COX 2, maar toch verschillende gevoeligheid -> sommige
preferentieel COX-1 inhibitie, andere preferentieel COX-2 inhibitie
7
