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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
Q

Gout prophylaxis

A

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
Q

When is gout prophylaxis especially important? (8)

A

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
Q

Allopurinol MOA

A

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
Q

Allopurinol indications

A

Prohpylaxis of:
Gout
Uric acid and calcium oxalate renal stones
Hyperuricaemia associated with chemotherapy

29
Q

Allopurinol Cautions

A

Do not start during acute phase but continue if attack develops
Ensure adequate fluid intake
Cover with NSAID/colchicine when starting

30
Q

Allopurinol SE (4)

A

GI disturbances
Rash
Blood disorders
Hypersensitivity reactions

31
Q

Allopurinol interactions (5)

A 
Amoxicillin (rash)
ACEi(leucopenia)
Azathioprine (toxicity)
Bendroflumethiazide (hypersensitivity)
Warfarin (increased anticoagulant effect)
32
Q

Allopurinol monitoring

A

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
Q

DMARD drugs which affect the immune process (5)

A

Hydroxychloroquine, Methotrexate, Azathioprine, Ciclosporin, Leflunomide

34
Q

DMARD Drugs which affect the disease process (3)

A

Gold, Penicillamine, Sulfasalazine

35
Q

DMARD Biological agents (6)

A

Infliximab, Etanercept, Adalimumab,Abatacept, Anakinra, Rituximab

36
Q

For adults with newly diagnosed active RA, offer first-line treatment with…

A

DMARD monotherapy using methotrexate, leflunomide or sulfasalazine ideally within 3 months of onset.

37
Q

What should be considered in addition to starting a new DMARD in RA

A

Consider bridging short-term steroids when starting a new DMARD.

38
Q

When should you offer additional DMARD in combination with 1st line monotherapy?

A

when remission/low disease activity has not been achieved despite dose escalation.

39
Q

Sulfasalazine MOA

A

Mechanism is poorly understood but metabolites (5-ASA) thought to have anti-inflammatory/immunosuppressive actions

40
Q

Sulfasalazine SE (7)

A 
GI disturbances
Orange secretions
Pancreatitis
Blood disorders
Hepato/renal toxicity
Skin reactions
Reversible oligospermia
41
Q

Sulfasalazine interactions (1)

A

Reduces absorption of digoxin

42
Q

Sulfasalazine CI (1)

A

Salicylate allergy

43
Q

Biological agents - Tumour necrosis factor inhibitors (4)

A
  • Infliximab, adalimumab, entanercept, golimumab
44
Q

Biological agents; Anti-IL1 therapy (1)

A
  • Anakinra
45
Q

BA Anti-CD20 therapy

A
  • Rituximab
46
Q

BA Anti-IL6 receptor therapy

A
  • Tocilizumab
47
Q

BA

T-cell co-stimulator modulator

A
  • Abatacept
48
Q

Biological therapy for RA indications

A

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
Q

Inflixamab MOA

A

Monoclonal antibody which inhibits TNF-α

50
Q

Infliximab CI (2)

A

Severe infections

Heart failure

51
Q

Infliximab SE (6)

A 
Hypersensitivity reactions
Heart failure/arrhythmias
Skin disorders
Lung problems
GI disorders
Reports of blood disorders (including malignancy) and infections
52
Q

Infliximab cautions (4)

A

Malignancy
•Hepatitis B
•Pregnancy
•Tuberculosis

53
Q

Infliximab considerations prior to starting (5)

A
  • 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
Q

Methotrexate MOA

A

Dihydrofolate reductase enzyme inhibitor

55
Q

Methotrexate indications (3)

A

Rheumatoid arthritis
Cancer therapy
Crohn’s disease

56
Q

Methotrexate SE (5)

A 
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
Q

Methotrexate contraindications (5)

A 
Active infection
Ascites
Pleural effusion
Severe renal impairment
Teratogenic in pregnancy
58
Q

Methotrexate interactions (2)

A

Trimethoprim/Co-trimoxazole (severe bone marrow depression)

NSAIDs (toxicity)

59
Q

Methotrexate considerations (5)

A 
Avoid live vaccines
Co-prescribe Folic Acid
Contraception (m&f)
Pre-screening tests
Monitoring requirements
60
Q

Methotrexate monitoring

A

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
Q

Methotrexate monitoring following dose increase

A

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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