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Y4 PPT > B44 - OA, gout, RA > Flashcards

B44 - OA, gout, RA Flashcards

1
Q

Non pharmacological Mx osteoarthritis (8)

A

weight loss if obese/overweight; physiotherapy; appropriate footwear; heat/cool packs; pacing; psychological support; assistive devices (walking sticks/tap turners); joint supports

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2
Q

1st line analgesia OA

A

Start with paracetamol/topical NSAID

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3
Q

2nd line analgesia OA

A

Escalate to oral NSAID if ineffective ensuring to stop the topical NSAID

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4
Q

3rd line analgesia OA

A

Escalate to weak opioids such as codeine if required
Adjuncts
-Topical capsaicin cream can be useful for hand/knee OA
-Intra-articular steroid injections can be considered for moderate/severe pain

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5
Q

NSAID MOA

A

COX inhibitors

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6
Q

NSAID SE (8)

A

GI disturbance
Renal insufficiency
Salt/water retention
Hyponatraemia/hyperkalaemia(prostaglandin antagonises ADH and mediates renin secretion)
Cardiovascular effects (stoke, especially diclofenac/high dose ibuprofen)
Hypersensitivity reactions (asthma, angioedema, rhinitis)
Headaches/dizziness
Skin reactions

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7
Q

Why does the side effect profile of NSAIDs vary?

A

Different drugs have different degree of selectivity for inhibition of COX-1 or COX-2. The degree of COX selectivity will also depend on the dosage used.

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8
Q

What (4) steps can you take to reduce the risk of NSAID gastro-intestinal side effects?

A

Lowest dose, shortest time.
Take with food
Prescribe a PPI alongside
Consider a selective NSAID (e.g. COX-2 inhibitor) instead

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9
Q

Name 3 COX 2 inhibitors

A

Celecoxib, etoricoxib, parecoxib

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10
Q

Benefits of COX 2 over COX 1 NSAID

A

Reduced side effect profile

Less likely to cause GI disturbance

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11
Q

Cautions of COX 2 over COX 1 NSAID

A

Risk of myocardial infarction if known IHD or risk factors

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12
Q

NSAID contraindications (6)

A 
GI bleeding/ulceration
Hypersensitivity reactions
Severe heart failure
Severe renal impairment
Varicella zoster infection
Avoid 3rd trimester of pregnancy
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13
Q

NSAID cautions (4)

A

Allergic disorders, Crohn’s disease, ischaemic heart disease and elderly

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14
Q

NSAID interactions (10)

A 
Warfarin
Direct oral anti-coagulants
Bisphosphonates
Anti-platelet agents
SSRIs
Steroids
Methotrexate
ACEi
Diuretics
Cephalosporins
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15
Q

When to refer OA for joint surgery (3)

A

Ensure that the person has been offered at least the core (non-surgical) treatment options

  • Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment.
  • Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain
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16
Q

1st/2nd line for acute gout

A

NSAID or colchicine. Colchicine more likely used in patients who are unable to tolerate NSAIDs or if there are cautions/contraindications.

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17
Q

Colchicine MOA in gout (4)

A
  • Reduced production of TNF alpha by macrophages inhibiting priming of neutrophil leucocytes
  • Inhibits production of chemotaxins preventing attracting leucocytes to inflamed tissues
  • Disrupts assembly of microtubules in neutrophil leucocytes impairing adhesion to endothelial cells
  • Inhibit release of enzymes and free radicals by neutrophils preventing damage to the joint
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18
Q

Colchicine overall action in gout

A

Prevention ofactivation, migrationand action ofneutrophils withinthe joint space

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19
Q

Colchicine indications (2)

A
  • Gout

* Familial Mediterranean fever

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20
Q

Cochicine SE (5)

A 
GI disturbances
•Blood disorders
•GI haemorrhage
•Hepatic/renal impairment
•Myopathy
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21
Q

Colchicine CI (2)

A

Blood disorders

•Pregnancy

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22
Q

Colchicine interactions

A 
Increased toxicity:
•Macrolides
•Anti-virals/fungals
•CCB
•Grapefruit juice

Myopathy:
•Lipid lowering therapy

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23
Q

Dose and length of colchicine course

A

Advised to take for 1-2 days after the acute attack has resolved. Pain relief usually begins by 18 hours and is maximal by 48 hours.
Dose is 500 micrograms 2-4 times a day, with a maximum of 6mg per course so use is restricted to 3-6 days.

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24
Q

Gout non-pharm advice (7)

A

Weight loss, reduction in alcohol and red meat/seafood consumption, keep hydrated, regular exercise, use low fat dairy products, smoking cessation

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25
Gout prophylaxis
Urate lowering therapy should be discussed and offered to all people with a diagnosis of gout. Allopurinol is the recommended first-line agent. Start ULT after the acute attack has resolved.
26
When is gout prophylaxis especially important? (8)
i2 or more attacks in the last 12 months, tophi, chronic gouty arthritis, joint damage, renal impairment, history of urinary stones, diuretic use, younger age at onset.
27
Allopurinol MOA
Xanthine oxidase inhibitor, reducing uric acid formation. Although this leads to increased levels of xanthine and hypoxanthine, these do not crystallise as are more water-soluble
28
Allopurinol indications
Prohpylaxis of: Gout  Uric acid and calcium oxalate renal stones Hyperuricaemia associated with chemotherapy
29
Allopurinol Cautions
Do not start during acute phase but continue if attack develops Ensure adequate fluid intake Cover with NSAID/colchicine when starting
30
Allopurinol SE (4)
GI disturbances Rash Blood disorders Hypersensitivity reactions
31
Allopurinol interactions (5)
``` Amoxicillin (rash) ACEi (leucopenia) Azathioprine (toxicity) Bendroflumethiazide (hypersensitivity) Warfarin (increased anticoagulant effect) ```
32
Allopurinol monitoring
Check serum uric acid level and renal function every 4 weeks until within target range and then annually thereafter. Aim is <300 micromol/l. Titrate the dose if not reached.
33
DMARD drugs which affect the immune process (5)
Hydroxychloroquine, Methotrexate, Azathioprine, Ciclosporin, Leflunomide
34
DMARD Drugs which affect the disease process (3)
Gold, Penicillamine, Sulfasalazine
35
DMARD Biological agents (6)
Infliximab, Etanercept, Adalimumab, Abatacept, Anakinra, Rituximab
36
For adults with newly diagnosed active RA, offer first-line treatment with...
DMARD monotherapy using methotrexate, leflunomide or sulfasalazine ideally within 3 months of onset.
37
What should be considered in addition to starting a new DMARD in RA
Consider bridging short-term steroids when starting a new DMARD.
38
When should you offer additional DMARD in combination with 1st line monotherapy?
when remission/low disease activity has not been achieved despite dose escalation.
39
Sulfasalazine MOA
Mechanism is poorly understood but metabolites (5-ASA) thought to have anti-inflammatory/immunosuppressive actions
40
Sulfasalazine SE (7)
``` GI disturbances Orange secretions Pancreatitis Blood disorders Hepato/renal toxicity Skin reactions Reversible oligospermia ```
41
Sulfasalazine interactions (1)
Reduces absorption of digoxin
42
Sulfasalazine CI (1)
Salicylate allergy
43
Biological agents - Tumour necrosis factor inhibitors (4)
- Infliximab, adalimumab, entanercept, golimumab
44
Biological agents; Anti-IL1 therapy (1)
- Anakinra 
45
BA Anti-CD20 therapy
- Rituximab 
46
BA Anti-IL6 receptor therapy 
- Tocilizumab 
47
BA | T-cell co-stimulator modulator
- Abatacept 
48
Biological therapy for RA indications
Biological therapies are indicated if in addition to steroids, two trials of six months of DMARD monotherapy or combination therapy (at least one including methotrexate) should fail to control symptoms/prevent disease progression. Should only be continued if there is an adequate response six months after starting.
49
Inflixamab MOA
Monoclonal antibody which inhibits TNF-α 
50
Infliximab CI (2)
Severe infections   | Heart failure
51
Infliximab SE (6)
``` Hypersensitivity reactions Heart failure/arrhythmias Skin disorders Lung problems  GI disorders Reports of blood disorders (including malignancy) and infections ```
52
Infliximab cautions (4)
Malignancy •Hepatitis B •Pregnancy •Tuberculosis
53
Infliximab considerations prior to starting (5)
- Patients should be up-to-date with immunisations before initiating treatment - Assess for active and latent TB and treat accordingly, advising patients to attend if develops symptoms of TB - Contraception is required for up to 6 months after last dose - Monitor for reactivation of hepatitis B - Periodic skin examination for non-melanoma skin cancer
54
Methotrexate MOA
Dihydrofolate reductase enzyme inhibitor
55
Methotrexate indications (3)
Rheumatoid arthritis Cancer therapy Crohn’s disease
56
Methotrexate SE (5)
``` GI disturbances Stomatitis – discontinue Myelosuppression Pulmonary, GI, Renal and Liver toxicity Skin reactions ``` Stomatitis – may be first sign of GI toxicity Pulmonary – pneumonitis and pulmonary fibrosis Patients should be warned to report the onset of any features of: -Blood disorders – sore throat, bruising, mouth ulcers -Hepatotoxicty – abdominal pain, N+V, dark urine -Respiratory effects – SOB, cough
57
Methotrexate contraindications (5)
``` Active infection Ascites Pleural effusion Severe renal impairment Teratogenic in pregnancy ```
58
Methotrexate interactions (2)
Trimethoprim/Co-trimoxazole (severe bone marrow depression) | NSAIDs (toxicity)
59
Methotrexate considerations (5)
``` Avoid live vaccines Co-prescribe Folic Acid Contraception (m&f) Pre-screening tests Monitoring requirements ```
60
Methotrexate monitoring
Pre-treatment screening: pregnancy test, FBC, U&E and LFT | FBC, U&E and LFT every 1-2 weeks until therapy stabilised and then 2-3 months thereafter
61
Methotrexate monitoring following dose increase
If dose is increased, monitor every two weeks until dose is stable for six weeks, then revert to previous schedule.

Y4 PPT (10 decks)

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