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Therapeutics > Arthritis > Flashcards

Arthritis Flashcards

1
Q

Factors influencing management of RA

A

Level of disease - early use of DMARDs, DMARDs vs symptomatic relief
Stage of therapy
Regulatory restrictions
Patient preference

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2
Q

Symptomatic management of RA

A

Paracetamol
NSAIDs - in early mx or acute flare; selective (celecoxib) or non-selective (ibuprofen); bridges to DMARDs
Opioids - weak (codeine, tramadol) or strong (morphine, pethidine)
Glucocorticosteroids - anti-inflammatory and immunosuppressive effect; decrease inflammatory cytokines
Intra-articular steroids - methylprednisolone, betamethasone. Indicated when only a few joints are involved
DMARDs - arrest or slow progression of bone and cartilage destruction

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3
Q

Side effects of glucocorticosteroids

A

Occur with prolonged use of high doses
Can lead to cushings
Cause DM and HPT
Psychological: sleep disturbances, mood changes, psychosis
MSK: osteoporosis, myopathy, bone necrosis

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4
Q

Side effects of intra-articulate steroids

A

Crystal arthropathy
Skin atrophy
Pigment changes

Limited to 4 per year

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5
Q

Examples of DMARDs and duration of therapy

A

Methotrexate, chloroquine, sulfasalazine

Takes between 6/52 and 6/12 to see result therefore therapy must be continued up until then

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6
Q

Features of osteoarthritis

A

Advanced age
Different joint profile - cervical NS lumbar spine, 1st CMJ, DIP joint, hip, knee
Stiffness pattern
Exam: crepitus, bony enlargement, decreased ROM, malalignment, tenderness
Synovial fluid less active
Radiological features present
Pattern of presentation

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7
Q

Management of osteoarthritis

A 
Non-drug measures:
A. Physic
B. Weight loss
C. Braces and insoles
D. Exercise
E. Assistive devices
F. Surgery
Drug measures: 
A. Paracetamol
B. NSAIDs - avoid LT when possible
C. Weak opioids
D. Adjuvants (amitriptyline) 
E. Intra-articular steroids - when effusions or signs of inflammation
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8
Q

3 phases of gout

A

Acute gout
Inter critical period
Chronic tophaceous gout

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9
Q

Features of acute gout

A 
Painful inflamed single joint
Maximal pain between 12-24 hours
Synovial fluid with - bifringent
Hyperuricaemia may be absent
Complete resolution of symptoms between attacks
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10
Q

Long term complications of gout

A

Urate crystal stones

Renal impairment

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11
Q

Management of acute gout

A

Treat the acute attack

Anti-inflammatories: NSAIDs, colchicine, corticosteroids

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12
Q

Management of inter critical and chronic gout

A

Objectives: prevent further attacks, prevent complications
Non-pharm mx: diet
Pharm mx:
A. Decrease uric acid production - xanthine oxidase inhibitors (allopurinol)
B. Improve uric acid excretion - probenecid

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13
Q

Methotrexate MOA

A

Methotrexate metabolized to polyglutamate (active)
Together inhibit key enzymes -> interferes with metabolic processes (carbon metabolism, purine synthesis and pyramidine synthesis) -> alters intracellular nucleotide pools and increases adenosine release -> antirheumatic effect

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14
Q

Methotrexate contraindications

A 
Pre-existing blood dyscrasias
Renal or hepatic disease
Previous or existing herpes or varicella infections
Serous effusions
Pregnancy
Lactation
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15
Q

Side effects of methotrexate

A

BM suppression
Mucosal ulceration
Hepatotoxicity
Nephropathy
Hyperuricaemia
Derm - alopecia, rash, pigmentation, urticaria
Other - headache, drowsiness, malaise, fatigue, blurred vision

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16
Q

Use of methotrexate in RA

A 
Start slow and adjust dose as per response
Folic acid supplemented with every dose
Folinic acid rescue if complications
No live vaccines while on methotrexate 
WOMCBP family planning
17
Q

Drug interactions of methotrexate

A

NSAIDs, aspirin, probenecid - decrease clearance

Phenytoin, cotrimoxazole, trimethoprim - additive anti-folate activity

18
Q

Sulfasalazine side effects

A

Nausea and vomiting
Headaches
Rashes
Can potentiation anti-folate activity of methotrexate and phenytoin
Rare: hemolytic anemia, neutropenia, methaemaglobinaemia, thrombocytopenia , reversible infertility in me

19
Q

Use of sulfasalazine in RA

A

Slows radiological progression
Can be used with methotrexate
Is she during pregnancy
Contraindicated in patients with sulphur allergy

20
Q

Primary use of chloroquine and use in RA

A

Primary use - anti-malarial

RA- may suppress T-lymphocyte response -> anti-inflammatory

21
Q

Problems with use of chloroquine

A

Concentrates melanin-containing cells, including eyes -> irreversible retinal damage therefore require 6/12ly eye exams
Can cause haemolysis in G6PD deficiency

22
Q

Mechanism of colchicine anti-inflammatory effect

A

Binds intracellular protein (Tubulin) -> prevents polymerization into microtubules and inhibits leukocyte migration and phagocytosis

23
Q

Colchicine adverse effects and contraindications

A

Side effects:
A. Common- GI intolerance (nausea, vomiting, diarrhea, abdo pain)
B. Uncommon- alopecia
C. Rare- hypersensitivity, BM suppression, myopathy

Contraindications- renal impairment

24
Q

Side effects of allopurinol

A

Common- hypersensitivity - can be fatal severe toxic syndrome in patients with renal failure
Uncommon- GI disturbances, drowsiness, headaches
Rare- BM suppression, peripheral neuropathy, arthralgias, myalgia, jaundice

25
Q

When should colchicine and probenecid not be used and why

A

Not used in an acute attack or within 4/52 after

Can trigger an acute attack

26
Q

MOA probenecid

A

Blocks URAT (uric acid reabsorption) -> uricosuria

27
Q

Contraindications to and interactions of probenecid

A

Contraindications- renal stones, blood dyscrasias, GFR

28
Q

Side effects of probenecid

A

Common- headaches, nausea, vomiting, flushing, dizziness, urinary frequency
Rare- anaplastic anemia if G6PD deficiency, nephrotic syndrome, hepatic necrosis, hypersensitivity reactions

29
Q

Diagnostic criteria of rheumatoid arthritis

A 
> 6/52:
A. Morning stiffness
B. Arthritis in >3 joint areas - common: MTP, MCP, PIP, wrist, elbow, knee, ankle
C. Arthritis of hands
D. Symmetric arthritis

Rheumatoid nodules
Serum rheumatoid factor
Radiographic changes

> 4= RA

Therapeutics (7 decks)

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