Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Pharmacology > Bone/Joint > Flashcards

Bone/Joint Flashcards

1
Q

role of COX 1 and COX 2

A

COX 1- preserves GI mucosal integrity, platelet activity, maintain intragolmerular pressure (kidneys)

COX 2- pain & inflammation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

COX 2 selective NSAID exs

A

celecoxib & diclofenac

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

first line tx OA

A

NSAIDs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what NSAID strongly recommended for OA in knee

A

topical (& also maybe for hand)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

should OA in hip be tx with topical NSAID

A

NO bc won’t penetrate deep joint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

how long to trial NSAID agent for OA and why

A

2-3 weeks bc analgesia works within hours but anti-inflammatory takes 2-3 weeks
if insufficient response after this timeframe, consider another NSAID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

SE of all NSAIDs

A

GI, renal, hepatic, CV, CNS, HTN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

preferred OA agent if patient has high GI risk

A

COX 2 inhibitor
with PPI if severe risk, without for moderate risk OR non selective with PPI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

COX 2 inhibitors have great risk of what complication

A

MI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

common drug interactions with NSAIDs

A

aspirin, warfarin, oral hypoglycemics, antiHTN, lithium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

when is APAP used for OA

A

short-term, episodic use in those who can’t tolerate/contraindications to NSAIDs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

when to start duloxetine for OA

A

if suboptimal response to NSAIDs
use as adjunct

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what SNRI/SSRI/TCA etc should be used to tx OA?

A

ONLY duloxetine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

duloxetine SE

A

nausea, dry mouth, somnolence, constipation, decreased appetite, hyperhidrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what opioid is recommended for OA and when

A

tramadol only when other tx has failed or if pt has contraindications

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

adverse effects tramadol

A

dizziness, vertigo, n/v/c, lethargy
RARE seizures
serotonin syndrome if used w/ other serotenergic agents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

ex of when opioid other than tramadol to tx OA and why

A

severe pain where alternatives inadequate or contraindicated
Ex: renal fail, HF, anticoagulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

special pt education for opioid combo

A

clear instructions to limit OTC APAP to avoid accidental OD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

intra-articular therapy
ex
when is it used

A

after failure of first-line oral/topical NSAIDs
glucocorticoids and hyaluronic acid for IA injection
(glucocorticoids strongly > hyaluronic acid)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what glucocorticoids for OA

A

less solubility (& injection)
methylprednisolone & triamcinolone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

how long does IA (intra-articular therapy) last and how often dosing interval

A

lasts for 3 weeks but cannot be injected more than every 3 months d/t risk of joint damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

concerns with IA

A

loss of hyaline cartilage and acceleration of OA progression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

postinjection flare after IA

A

mimics flare of arthritis
tx with cold compresses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

glucosamine and chondroitin for OA

A

not supported d/t inconsistent efficacy
if used should be adjuncts to evidence-based therapies and d/c after 3-6 mo if no benefit noted

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

SE glucosamine

A

shellfish allergy
high glucose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Capsaicin for OA

A

not effective for acute pain, takes 2 weeks of daily admin to relieve pain
superficial joints only

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

how long to try APAP for OA tx

A

4000mg daily in divided doses x4-6 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

risk factors for osteoporosis (OP)

A

menopause d/t loss of estrogen (esp if early < 45 y/o)
female
> 65
asian, white
hx fragility fx before age 50
osteoporatic fx first degree relative
low BMI
RA
glucocorticoid therapy
smoking
ETOH (> 3 drinks daily)
loss of height
secondary osteoporosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

secondary causes of OP

A

ETOH
CKD
COPD
cushings
DM
CF
ED
GI
vit D deficiency

anticoag
anticonvulsants
steroids
lithium
PPI
SGLT2i
Thiazolidinedoines
thyroid supps d/t overreplacement
TPN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

recommended amount calcium men/women/ages

A

calcium
1000mg men age 51-70
1200mg women > 51 y/o and men > 71

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

osteopenia T score

A

-1.0 to -2.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

osteoporosis T score

A

less than -2.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

how much Ca intake from diet men/women > 50 typically get

A

600-700mg/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

when to start pharm. therapy for OP (3 situations)

A
  1. h/o hip/vertebral fx
  2. T score -2.5 or less femoral neck/spine
  3. osteopenia and at least 3% 10 year probability of hip fx or 20% 10 year probability major osteoporosis fx
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

risk of too much Ca

A

> 1200 mg/day > kidney stones
2500 mg/day > hypercalciuria/hypercalcemia
increase CV event

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

supplement doses of Ca limit

A

500-600mg of elemental Ca per dose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Ca carb consideration

A

Take WITH food for absorption

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Ca citrate consideration

A

better absorbed in pt on PPI/acid suppression bc acidic environment not needed for absorption
Take w/ or w/o food

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

adverse effects Ca supplement

A

constipation, bloating, cramps, flatulence esp. calcium carb
changing diff. salt form may help

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Ca with other meds

A

Ca salt reduce absorption of iron, antibiotics like tetracycline and fluoroquinolones so take 2 hr prior to 6 hours after

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

vit D supplement dose

A

800-1000 IU daily all adults 50 and older
MAX 4000 IU daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

tx vit d deficienct

A

5000 IU of cholecalciferol (d3) daily x8-12 weeks
then decrease to 1500-2000 IU after labs rise above 30

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

biphosphonate names &
mech. of action

A

first line tx osteoporosis

alendronate, risedronate, zoledronic acid ….. ibandronate for postmenopausal osteoporosis only & is second line therapy

bind to bone matrix & inhibit osteoclast activity; tx osteopenia & osteoporosis mostly in hip & spine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

what happens when biphosphonate d/c’d

A

sustained benefits in fracture risk reduction up to 5 years after

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

bisphosphonate adverse effects (acute)

A

bone/muscle/joint pain (resolves when med stopped)
upper GI (n/v/d, severe esophageal irritation)
once week admin of oral can decrease risk
IV zoledronic acid= acute phase rx (flu-like sx); prevent and tx with APAP
AKI if renal disease, dehydration, diuretics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

adverse effects long term biphosphonate use

A

osteonecrosis of jaw (ONJ) & atypical femoral fractures (AFF)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

what should pt do BEFORE starting biphosphonate

A

major dental work

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

how long should you be on biphosphates and what is recommended to min SE

A

10 years oral, 6 IV
drug holidays after 5 years oral, 3 years IV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

admin considerations with biphosphates

A

after overnight fast, plain water, remain upright x30 min
dont take w/ other meds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

contraindications biphosphates

A

hypersensitivity, hypercalcemia, pregnancy, renal impair (cr clear < 30-35), esophageal abnormalities, GI malabsorption, can’t remind upright x30 min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

denosumab

A

broad-spectrum twice yearly inj. human monoclonal antibody decreases osteoclasts to tx OP /reduce fx

first line for osteoporosis in many people and if can’t tol biphosphates.

52
Q

downfall of denosumab vs bisphos.

A

BMD decreases will be seen within months of discontinuation unlike with biphos.

53
Q

denosumab SE

A

back pain, arthralgia, fatigue, HA, derm rx, diarrhea, nausea

SERIOUS
hypophosph./Ca, dyspnea, skin/other infections
** hypocalcemia needs to be corrected before use

Drug holidays NOT recommended

54
Q

what to do before denosumab therapy

A

correct hypocalcemia (risk higher in CKD but can still be used)

55
Q

first line tx for OP in patients with prior fractures or those deemed very high risk

A

parathyroid hormone analogs (injections)
teriparatide & abaloparatide (postmenopausal only)

56
Q

adverse effects parathyroid hormone analogs

A

nausea, HA, leg cramps, ortho hypotension, inject .iste, hypercalciruia, hypercalcemia
abaloparatide= palpitations
osteosarcoma observed in animals

57
Q

contraindications parathyroid hormone analogs

A

preexisting hypercalcemia, hyperparathyroid, hx skeletal radiation

58
Q

tx duration parathyroid hormone analogs

A

2 years
BMD declined once stopped but fx reduction x1-2 years
switch to biphos. or denosumab once tx maxed out to prevent BMD loss

59
Q

antisclerostin antibody & when indicated

A

romosozumab 210mg 2 SQ injections once monthly
tx for OP; greater reduction in vertebral fx rate

indicated for postmenopausal women at high risk fx who failed/intolerant other tx

60
Q

tx duration romosozumab

A

12 months
effect wanes after 1 year
start biphosph. or denosumab once stopped

61
Q

romosozumab SE

A

inject. site, arthralgias, HA, skin-related hypersensitivity

SERIOUS
increased CV events > MI, stroke, CV death so contraindicated if MI or stroke within past year

62
Q

estrogen agonists/antagonists for OP

A

raloxifene (and less common bazedoxifene)
estrogen like activity on bones > reduces bone resorption decrease bone turnover
decrease breast cancer risk
Only used in select women w/ high risk breast cancer and inability to take other agents

63
Q

adverse effects raloxifene

A

hot flushes, leg cramps, increase risk venous thromboembolism

64
Q

adverse effects raloxifene

A

hot flushes, leg cramps, increase risk venous thromboembolism

65
Q

calcitonin

A

regulates Ca levels; inhibits bone resorption, reduces vertebral fx risk ONLY for OP (only nasal formulation shows benefit)
reserved for pt who can’t tolerate other agents
short-term relief back pain

66
Q

adverse effects calcitonin

A

(intranasal) rhinitis, dryness, irritation

67
Q

hormone therapy for OP

A

estrogen alone or w/ /progestin (HRT) reduces vertebral & hip fx risk but risks limit use (breast cancer, clot)

considered in post-menopause with hysterectomy intol. of other therapies and has vasomotor sx

68
Q

combination therapy recommendations for OP

A

not recommended d/t high cost and lack of long term safety
reasonable to add biphosph. or denosumab if pt using raloxifene to reduce breast cancer risk

69
Q

what’s recommended for mod-high risk of fx, 40 y/o and up, taking glucocorticoids for 3 months or longer

A

biphosphonate therapy
if younger than 40, DXA with z-score recommended and optimal Ca/vit D intake

**BMD testing every 1-3 years

70
Q

if pt taking steroids who qualify for biphosph. therapy cannot take it, what do you do

A

IV bisphosh, then teriparatide, denosumab, raloxifene in that order
BMD testing every 1-3 years

71
Q

contraindications to biphosphonates

A

inability to remain upright x30 min, renal insufficiency (CrCl < 30)

72
Q

special factors to consider for indications of meds for OP

A

most tx regimens are only for post menopausal women or male osteoporosis

73
Q

OP meds that are only for PM women

A

antisclerostin antibody (romosozumab)
estrogen agonists/antagonists aka SERMS (raloxifene & bazedoxifene/conjugated estrogens)
calcitonin
ibandronate (a biphosphonate)
abaloparatide (a parathyroid hormone analog)

74
Q

first line tx for OP if prior fractures or very high risk

A

parathyroid hormone analogs: teriparatide (injection; men & women) & abaloparatide (PM women only)

75
Q

what’s recommended for postmenopausal women at high risk of fx (hx or mult risk factors) who FAILED/intolerant of other tx options

A

antisclerostin antibody (Romosozumab)

76
Q

tx for select women with high risk breast cancer and inability to take other agents

A

SERMS (estrogen agonists/antagonists)
raloxifen & bazedoxifene

77
Q

what role do glucocorticoids play in OP

A

increase bone resorption, inhibiting bone formation, and changing bone quality
Bone mass lost in initial 3-6 mo of therapy
higher incidence of vertebral fx

78
Q

meds for preventing OP in pre menopausal women

A

alendronate (a biphosphonate)
zoledronic acid (a biphosphonate)

79
Q

whats hyperuricemia

A

high serum uric acid > 6.8
not all people show sx

80
Q

risk factors to gout

A

unhealthy diet (purines, fructose, alcohol), lack of exercise, obesity, male sex
trauma & surgery may trigger by increasing uric acid
certain meds
CKD

81
Q

gout is an independent risk factor of….

A

coronary heart disease

82
Q

should people with gout continue low dose aspirin for MI/stroke prevention

A

yes- benefits outweigh risks

83
Q

long term consequences of gout and hyperuricemia

A

joint destruction, tophi, nephrolithiasis, nephropathy

84
Q

signs of acute gout attack

A

elevated WBC, ESR, tenderness/swelling/loss of function to one joint
not all pt have hyperuricemia

85
Q

opioids and gout

A

play NO role bc it’s inflammatory

86
Q

NSAIDs for gout

A

all similar efficacy, FDA approved:
naproxen
indomethacin (greater SE esp GI)
sulindac

dose at higher end of therapeutic range for shortest duration possible (until 24 h after sx resolve)

87
Q

who should avoid NSAIDs for acute gout

A

risk of peptic ulcers, anticoagulants, renal insufficiency, uncontrolled HTN, HF

88
Q

why is colchicine used less for gout

A

low therapeutic index and increased cost

89
Q

when is colchicine indicated for gout

A

when given within 36 hours of attack; best within 24 hours

90
Q

SE colchicine and what to do

A

GI (n/v/d & abdominal pain) which warrant LOWER DOSE because GI effects are forerunner of more serious systemic toxicity including myopathy and bone marrow suppression (neutropenia). Can occur w/o GI effects esp in renal impairment < 30

91
Q

what meds require colchicine dose reduction when given concurrently

A

p-glycoprotein or strong CYP3A4 inhibitors (clarithromycin, verapamil, ritonavir, cyclosporine, ranolazine)
use with caution with statins and liver failure

92
Q

tx of choice for acute gout attack

A

NSAIDs
then colchicine if have SE or failed NSAID therapy

93
Q

colchicine doses

A

1.2mg (two 0.6mg tabs) at onset of acute flare f/b 0.6mg 1 hour later
OR
0.6mg TID on first day of attack
*dose adjustment for renal insufficiency

94
Q

contraindications to colchicine

A

never used if currently taking for prophylaxis
was treated with med within past 14 days
cautions with liver disease
dose adjustment with renal insufficiency

95
Q

glucocorticoids for gout

A

when NSAIDs or colchicine contraindicated or not tolerated (esp d/t renal impair) or for polyarticular attacks or in the elderly
equally effective as NSAIDs
if 1-2 joints then can get intra-articular injection

96
Q

adverse effects & contraindications glucocorticoids

A

fluid retention, hyperglycemia, CNS stimulation, weight gain, GI upset, increased risk of infection

avoid in diabetes or monitor sugars closely
caution if h/o PUD

97
Q

corticotropin/adrenocorticotropic hormone (ACTH) for gout
efficacy and when indicated

A

similar efficacy to other gout tx but expensive; not first-line
indicated in pt unable to take meds orally

98
Q

interleukin-1 inhibitors for gout

A

canakinumab and anakinra
conditionally indicated if patients can’t tolerate or have contraindications to other anti-inflammatories
injective side rxn

99
Q

combo therapy for gout

A

severe polyarticular attacked esp in large joints
colchicine with NSAIDs or glucocorticoids
glucocorticoid injections can be used with any first line agents)

100
Q

when is urate-lowering therapy for gout indicated/not indicated

A

NOT indicated:
first gout attack, asymptomatic hyperuricemia
conditionally recommended if more than one acute attack but less than two per year but ALSO have mod/severe CKD, SUA > 9, urolithiasis

INDICATED:
freq. gout flares 2+ per year, radiographic evidence of gout, or at least one SQ tophus

101
Q

non pharm tx gout

A

exercise/weight loss
DASH diet , low/no alcohol, manage other comorbidities
low-nonfat dairy and veggies
cheery juice, flaxseed, celery root
d/c contributing meds if clinically appropriate (like hydrochlorothiazide)

102
Q

prophylactic gout tx exs

A

allopurinol, febuxostat, probenecid, and/or pegloticase

103
Q

can urate-lowering therapy be started during acute gout attack

A

yes IF anti-inflammatory tx was started and should be continued during acute attacks

104
Q

prophylactic treatment reserved for refractory gout

A

Pegloticase (recombinant urate oxidase)

105
Q

first line tx gout prophylaxis

A

allopurinol
affordability and efficacy NOT associated with renal decline in CKD

106
Q

allopurinol

A

first line therapy most patients
XOI agent
half life 2-3 hours
recommended in mod-severe CKD
ONLY start if anti-inflammatory tx is also initiated

107
Q

Why should allopurinol ONLY start if anti-inflammatory tx is also initiated

A

sudden shifts in SUA level from mobilization of tissue urate stores may precipitate or exacerbate gouty arthritis

108
Q

if person being treated with colchicine for acute attack, when do you initiate prophylactic colchicine

A

12 hours after last tx dose

109
Q

how long to continue prophylactic gout therapy

A

acute gout receive prophylaxis when ULT is started and continue 3-6 months after no clinical evidence of gout activity and SUA target reached

110
Q

allopurinol start dose and titration in pt with and w/o renal insufficiency

A

100mg normal
50mg renal
*taper up Q2-5 weeks as tolerated to the SUA target even in pt with renal disease as long as monitored/educated
when not titrating, check SUA Q6 months
Treat for sx NOT to target SUA

111
Q

allopurinol SE

A

nausea, diarrhea uncommonly
generalized maculopapular rash can progress to Stevens-Johnson syndrome within first few months of therapy
*allopurinol hypersensitivity syndrome (rare but high mortality); patients should be screened via HLA and other risk factors (thiazide use, renal impairment, African american)

112
Q

allopurinol drug interactions

A

theophylline & warfarin effects increased
azathioprine & 6-mercaptopurine inhibited
increase risk skin rash if take with ampicillin

113
Q

febuxostat

A

nonpurine XOI structurally diff than allopurinol
no dose adjustment for renal

114
Q

what should be given with febuxostat and why?
when rx indicated?

A

low dose colchicine or NSAID for at least 6 months for anti-inflammatory prophylaxis d/t rapid reduction of SUA levels

rx febuxostat indicated if can’t tolerate allopurinol or cannot achieve SUA < 6

115
Q

adverse effects febuxostat, risk, and requirements during therapy

A

nausea, arthralgias, rash, transient elevation of hepatic transaminases, CV events
higher CV mortality

period LFT

116
Q

probenecid mech of action, when indicated/not indicated/avoided
SE & pt education

A

uricosuric agent that bocks tubular reabsorption of uric acid & increases excretion

indicated= alternative first line if XOI therapy not tolerated/contraindicated ; can be added to XOI

contraindicated= urate overproducers, h/o urolithiasis or urate nephropathy. Avoided in CKD.

SE= GI (nausea), fever, rash, rarely hepatic toxicity

education= hydration and u/o to decrease stone formation. Some adovate alkalinizing urine

117
Q

when to switch XOI agent (allopurinol, febuxostat) or add uricosuric agent (probenecid)

A

when SUA remains > 6, more than 2 gout flares annually, SQ tophi

118
Q

agent w/ mild uricosuric effects for HTN and gout

A

losartan
can combine with XOI

119
Q

agent w/ mild uricosuric effects for dylipidemia and gout

A

statins
can combine with XOI
fenofibrate not recommended bc of risks/SE

120
Q

lesinurad/when indicated

A

urice acid transporter 1
increases renal excretion SUA
coadmin w/ XOI if fail to meet target on XOI alone
withdrawn from market r/t business reasons

121
Q

Denosumab risk & how it’s mitigated

A

Denosumab has a Risk Evaluation and Mitigation Strategy (REMS)
program, in which the FDA requires that patients be informed of the risks associated with
denosumab use. In clinical trials, patients treated with denosumab had a higher rate of
infection.

122
Q

Raloxifene black boxed warning

A

Raloxifene carries a black boxed warning for increased risk of venous
thromboembolism and should be avoided in patients with a history of DVT.

123
Q

Zoledronic acid contraindication

A

Zoledronic acid is contraindicated in patients with CrCl less than 35
mL/min (0.58 mL/s)

124
Q

Romosozumab black boxed warning

A

Romosozumab carries a black boxed warning for increased risk of
myocardial infarction (MI), stroke, and cardiovascular death and should be avoided if stroke
or MI occurred within the past year.

125
Q

antiresorptive agents for OP

A

Denosumab
Raloxifene

Pharmacology (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions