Pharmaceuticals That Cause Cutaneous Small-Vessel Vasculitis Should Be Screened During MTM
In a room full of patients with vasculitis, few would tell the same story about their illness. The name sounds simple, and they all share one symptom—inflamed blood vessels—but that’s often where the similarities end. Its causes are numerous, any organ system can be affected, and, as a result, many different symptoms appear. When it manifests as cutaneous small-vessel vasculitis, there’s a good chance it’s caused by an underlying autoimmune disease—or medications. That’s where pharmacists can help. When you combine pharmaceutical expertise with a working knowledge of this condition, you can target at-risk patients and advocate for an early diagnosis.
What Pharmacists Need to Know About Vasculitis
Vasculitis refers to a group of diseases that cause diverse symptoms ranging from mild to life-threatening, depending on the organ system involved. While the diagnosis may require a biopsy, physicians can often determine the type of vasculitis based on the physical exam and the size of the vessel involved.1 Here’s a rundown of the differential diagnoses for each vessel size, though the last category—small-vessel vasculitis—is most relevant for pharmacists:
- Giant cell arteritis
- Isolated aoritis
- Takayasu’s arteritis
- Aortitis in Cogan’s Syndrome
- Aortitis in Spondylarthropathies
- Kawasaki disease
- Polyarteritis nodosa
Small- and medium-sized arteries:
- Granulomatosis with polyangiitis (Wegener’s granulomatosis)
- ANCA-associated vasculitis
- Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
- Primary angiitis of the central nervous system
- IgA vasculitis (Henoch-Schonlein)
- Cryoglobulinemic vasculitis
- Anti-GBM disease (Goodpasture’s)
- Vasculitis related to rheumatoid arthritis, systemic lupus erythematosus (SLE) and Sjogren’s syndrome
- Drug-induced vasculitis
It’s essential for pharmacists to keep the last two items on the radar as they counsel patients. As the medication expert, you may help identify drug-induced vasculitis before a primary care physician. Additionally, you’re likely to encounter many patients with autoimmune disorders as they come in to the pharmacy to refill prescription medications or to search for topical OTC treatments to relieve skin rashes and inflammation.
Drug-Induced Cutaneous Small-Vessel Vasculitis
Small-vessel vasculitis may affect the renal, pulmonary, neurologic, musculoskeletal, gastrointestinal, and ear-nose-throat systems. However, it frequently manifests as cutaneous small-vessel vasculitis, or hypersensitivity vasculitis.2 The causes of cutaneous small-vessel vasculitis (CSVV) break down this way:3
- 50 percent of all cases are idiopathic
- 15 to 20 percent are caused by infections
- 15 to 20 percent are related to autoimmune diseases
- 10 to 15 percent arise from drug reactions
You’ll recognize CSVV by the appearance of palpable purpura and wine-colored papules with inflammation on the lower extremities. Symptoms such as pain and burning are common and some patients may develop ulcers or small lumps, which indicate deeper involvement.
Drug-induced CSVV usually affects only the skin, although it may cause a fever, arthralgias and myalgias and affect the kidneys or lungs. Experts speculate that drug-induced vasculitis may frequently go unreported or undiagnosed, which means pharmacists can pinpoint a problem by conducting a quick visual assessment during medication reviews. Many drugs are known to cause CSVV, including:
- Anti-thyroid drugs: propylthiouracil (the most frequently implicated drug)
- Antibiotics: cephotaxime, minocycline, benzylthiouracil, carbimazole, methimazole,
- Anti-tumor necrosis factor-a agents: adalimumab, etanercept, infliximab
- Non-steroidal anti-inflammatory drugs
- Psychoactive agents: clozapine, thioridazine
- Miscellaneous drugs: allopurinol, D-penicillamine, hydralazine, levamisole, phenytoin, sulfasalazine
Treatment and Pharmacist Intervention
Considering the complex nature of CSVV, one of the most important roles for pharmacists is to simply stay aware of the causative drugs, then assess patients taking those medications. It’s vital to catch drug-induced CVSS as early as possible—risks for systemic involvement increase in direct relation to the length of time on the medication. Your intervention may be the key to early diagnosis and treatment, as patients with mild cutaneous symptoms may not seek medical help.
Treatment depends on whether the patient has chronic CSVV, whether the cause can be identified, evidence of systemic involvement, and the severity of cutaneous involvement.
- Single occurrence: Initiate conservative treatment—remove the drug causing the problem and recommend bed rest and leg elevation. Medicate to relieve symptoms with topical corticosteroids or nonsteroidal anti-inflammatory drugs. A short taper of prednisone for widespread, ulcerative or necrotic disease may also be considered.
- Chronic CVSS: First-line treatment is colchicine, dapsone or both; second-line drugs to consider are mycophenolate mofetil, azathioprine and methotrexate.
- Refractory CVSS: Treatment regimen may include hydroxychloroquine, rituximab, cyclosporine or intravenous immunoglobulin.
Promote Positive Outcomes With a Proactive Approach
Health care teams are a growing trend for good reason: They’re often the best chance for optimal outcomes because they give patients better access to multiple specialists. This type of treatment approach is vital for diagnosing and treating multifaceted diseases such as CVSS. Pharmacists are crucial members of the team, so don’t hesitate to be the one to initiate a collaboration. You can serve as the bridge between patients and clinicians, which facilitates communication, keeps all providers aware of medication concerns, and promotes healthier patients.
Pharmaceutica North America provides bulk APIs, prescription drug products and OTC supplements, which are manufactured and distributed in accordance with cGMP at a FDA and DEA registered facility. Contact us today to talk about how we can support your pharmaceutical needs.
- “Vasculitis,” May 2015, http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Vasculitis ↩
- “A Practical Approach to the Diagnosis, Evaluation, and Management of Cutaneous Small-Vessel Vasculitis,” August 2014, http://www.medscape.com/viewarticle/828864_1 ↩
- “Drug-Induced Vasculitis: A Clinical and Pathological Review,” January 2012, http://www.njmonline.nl/getpdf.php?id=1131 ↩