BASIC - MSK Flashcards
1
Q
Names of NSAIDs?
A
Ibuprofen, diclofenac, etoricoxib
2
Q
Indications of NSAIDs?
A
- PRN for mild-to-moderate pain
- Regular treatment of pain related inflammation
3
Q
Mechanism of NSAIDs?
A
- Inhibit synthesis of prostaglandins from arachidonic acid by inhibiting cyclooxygenase (COX
- COX-1 stimulates prostaglandin synthesis essential to preserve gastric mucosa, maintain renal perfusion (by dilating afferent glomerular arterioles) and inhibit thrombus formation at the vascular endothelium
- COX-2 expressed in response to inflammatory stimuli stimulates production of prostaglandins that cause inflammation and pain
- Therapeutic benefits of NSAIDs are principally COX-2 inhibition and adverse effects by COX-1 inhibition
- Selective COX-2 inhibitors (e.g. etoricoxib) developed to reduce the adverse effects
4
Q
Side effects of NSAIDs?
A
- GI ulcers/gastritis
- Renal impairment
- Increased risk of MI/CVA
- Fluid retention
5
Q
Interactions of NSAIDs?
A
- GI Ulceration o Aspirin, corticosteroid - GI bleeding o Anticoagulants, SSRIs, venlafaxine - Renal Impairments o ACEi, diuretics
6
Q
Contraindications of NSAIDs?
A
o Severe renal impairment
o Heart Failure
o Liver failure
7
Q
Cautions of NSAIDs?
A
o Peptic ulcer disease
o GI bleeds
o CVD
8
Q
Prescription of NSAIDs?
A
- Available as tablets, suspensions, gels, suppositories, injectable
- Acute pain treatment should be stopped when resolved
- Taken with food to minimise GI upset
- Can use gastroprotection for patients at increased risk
9
Q
Names of oral glucocorticoids?
A
Prednisolone, hydrocortisone, dexamethasone
10
Q
Indications of oral glucocorticoids?
A
Allergic or inflammatory disorders (anaphylaxis, eczema, asthma, COPD)
Severe croup
Autoimmune disease (IBD, ITP, inflammatory arthritis)
Cancer treatment
Myasthenia Gravis, Polymyalgia rheumatica, GCA, Lupus
Proctitis
Joint injections
Adrenal insufficiency/Hypopituitarism
11
Q
Mechanism of oral glucocorticoids?
A
- Bind to cytosolic glucocorticoid receptors which upregulate anti-inflammatory genes and downregulate pro-inflammatory genes (cytokines, TNFa)
- Suppression of circulating monocytes and eosinophils
- Metabolic effects
o Increased gluconeogenesis
o Increased catabolism - Mineralocorticoid effects
o Stimulate Na and water retention and K excretion
12
Q
Side effects of oral glucocorticoids?
A
- Immunosuppression
- Diabetes mellitus
- Insomnia, psychosis and suicidal ideas
- Osteoporosis
- Metabolic
o Proximal muscle weakness, skin thinning with easy bruising and gastritis - Mineralocorticoid
o Hypertension, hypokalaemia and oedema - Prolonged
o Adrenal atrophy leading to Addisonian crisis if withdrawn suddenly
13
Q
Cautions of oral glucocorticoids?
A
- Infection
- Children (suppress growth)
- Hepatic or Renal impairment
14
Q
Interactions of oral glucocorticoids?
A
Risk of peptic ulceration – NSAIDs
Hypokalaemia – B2-agonists, theophylline, loop and thiazide diuretics
Affected by CYP450 enzymes
15
Q
Prescription of oral glucocorticoids?
A
o Can be given orally, IM, IV
o OD, taken in the morning to mimic natural circadian rhythm
o Consider use of bisphosphonates and PPIs if long-term and risk
16
Q
Monitoring of oral glucocorticoids?
A
o For children – height and weight monitored annually – refer to paediatrician if slow
o Prolonged treatment – HbA1c or DEXA scan
17
Q
Cessation of oral glucocorticoids?
A
o Abrupt withdrawal can lead to adrenal insufficiency
o Gradual withdrawal used if treatment >3 weeks, received >40mg, repeated evening doses
18
Q
Communication of oral glucocorticoids?
A
o Should feel better in 1-2 days
o Do not stop immediately
o Steroid card to carry round at all times
19
Q
Indications of methotrexate?
A
- Rheumatoid arthritis
- Crohn’s disease
- Chemotherapy – e.g. leukaemia, lymphoma and some solid tumours
- Severe psoriasis
20
Q
Mechanism of methotrexate?
A
- Inhibits dihydrofolate reductase, which converts dietary folic acid to tetrahydrofolate (FH4)
o FH4 needed for DNA and protein synthesis, so lack of it prevents cellular replication
o Actively dividing cells particularly sensitive so good for cancer - Anti-inflammatory and immunosuppressive effects
o Inhibition of IL-6, IL-8 and TNF alpha
21
Q
Side Effects of methotrexate?
A
- Sore mouth, GI upset (diarrhoea, nausea, vomiting)
- Neutropenia, leukopenia, thrombocytopenia (Agranulocytosis)
- Hepatitis, pneumonitis
- Long term use – hepatic cirrhosis, pulmonary fibrosis
22
Q
Contraindications of methotrexate?
A
- Active infection
- Pregnancy – teratogenic (both men and women taking drug need effective contraception during and for 3 months after stopping treatment
- Severe renal impairment
- Hepatic impairment in non-malignant conditions
23
Q
Cautions of methotrexate?
A
- Abnormal liver function
24
Q
Interactions of methotrexate?
A
- Methotrexate toxicity more likely with:
o NSAIDs, penicillins - Risk of haematological abnormalities in trimethoprim and phenytoin
- Risk of neutropenia increased in clozapine
25
Prescription of methotrexate?
- Oral dose, once weekly 7.5-20mg, adjusted according to response
- Folic acid prescribed to be taken on the other 6 days when methotrexate isn’t taken
- For cancer – given IV/IM/intrathecal
26
Important communication to patient of methotrexate?
- Report symptoms of sore throat, fever, bruising, bleeding, nausea, abdominal pain, dark urine, breathlessness
- Need contraception
- Give folic acid to reduce side effects
27
Monitoring of methotrexate?
- Before treatment – FBC, LFT, U&E and a pregnancy test
- 1-2 weekly until established
- 2-3 monthly thereafter
28
Indications of allopurinol?
- Prophylaxis of gout and uric acid/calcium oxalate renal stones
- Prophylaxis of hyperuricaemia in cancer
29
Mechanism of allopurinol?
- Xanthine oxidase inhibitor
| - Reduces xanthine to uric acid – lowers concentrations of uric acid
30
Side effects of allopurinol?
- Skin rash – mild to severe SJS or TENs
- Drug hypersensitivity syndrome
o Fever, eosinophilia, lymphadenopathy
- Acute gout triggered
31
Contraindications of allopurinol?
- Acute gout
| - Recurrent skin reaction
32
Cautions of allopurinol?
- Ensure adequate fluid intake (2-3 litres/day)
| - Start allopurinol before cancer treatment
33
Dose changes in renal/hepatic impairment of allopurinol?
- Dose reduction
34
Interactions of allopurinol?
- Allopurinol and amoxicillin risk of rash
| - Allopurinol and ACEi/thiazides – risk of hypersensitivity reactions
35
Prescription of allopurinol?
- Oral start at low dose and titrate according to uric acid levels to maintenance dose
- Typical 100mg initial and then up to 200-600mg
- Take after food
- NSAID or colchicine prescribed for 1 month after serum uric levels normalise to avoid acute attack
36
Communication of allopurinol?
- Take after meals
- Seek advice if rash develops
- Do not stop allopurinol in acute attack
37
Monitoring required of allopurinol?
- Uric acid levels checked 4 weeks after start/dose change
| - Aim for uric acid <300 and titrate dose
38
Names of calcium salts?
Calcium carbonate, calcium gluconate
39
Names of vitamin D analogue?
Colecalciferol
40
Indications of calcium salts and vitamin D?
- Osteoporosis
- Chronic kidney disease
- Severe hyperkalaemia (calcium gluconate)
- Hypocalcaemia if symptomatic or severe (<1.9)
- Vitamin D used in prevention and treatment of Vitamin D deficiency, including rickets (children) and osteomalacia (adults)
41
Mechanism of action in calcium and vitamin D?
- Calcium needed for muscles, nerves, bone and clotting
- Homeostasis controlled by PTH and vitamin D, which increase serum Ca and calcitonin which reduces Ca level
- Restoring positive Ca balance reduces rate of bone loss, restores Ca level in CKD
- In hyperkalaemia, calcium gluconate raises myocardial threshold potential, reducing excitability
42
Side effects of calcium salts?
- Dyspepsia
- Constipation
- Nausea
43
Interaction of oral calcium?
- Oral calcium reduces absorption of:
| o Iron, bisphosphonates, tetracyclines and levothyroxine
44
Prescription of calcium salts & vitamin D?
- Adcal D3 BDS contains calcium and vitamin D (cholecalciferol)
- Chew then swallow tablets
- Separate doses by 4 hours to medicines that interact
45
Monitoring in calcium salts?
- Check calcium levels regularly
46
Names of bisphosphonates?
Alendronic acid, disodium pamidronate, zoledronic acid
47
Indications of bisphosphonates?
- Alendronic acid – patients at risk of osteoprotic fragility fractures
- Pamidronate/Zoledronic acid – severe hypercalcaemia of malignancy, myeloma, breast cancer with bone mets
- Paget’s Disease
48
Mechanism of bisphosphonates?
- Reduce bone turnover by inhibiting action of osteoclasts, cells responsible for bone resorption
- Reduction in bone loss and improvement in bone mass
49
Side effects of bisphosphonates?
- Oesophagitis
- Hypophosphatemia
- Osteonecrosis of jaw
- Osteonecrosis of external auditory canal
- Atypical femoral fractures
50
Contraindications of bisphosphonates?
- Severe renal impairment (<35)
- Hypocalcaemia
- Upper GI disorders
51
Cautions of bisphosphonates?
- Smokers
| - Dental disease
52
Interactions of bisphosphonates?
- Absorption reduced if taken with calcium salts (including milk), antacids and iron salts
53
Prescription of bisphosphonates?
- For osteoporosis – alendronic acid oral 70mg once weekly
| - For severe hypercalcaemia – slow IV infusions
54
Communication to patient of bisphosphonates?
- Alendronic acid – swallowed whole >30 mins before breakfast or other medications with plenty of water, patient remain upright for 30 minutes afterwards to reduce oesophageal irritation
55
Monitoring of bisphosphonates?
- Osteoporosis – check Ca and Vit D before and during treatment, DEXA every 1-2 years
- Hypercalcaemia – Ca levels
