Bone/Joint Meds

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

Question 4

Answer 4

Question 5

Answer 5

Question 6

Answer 6

Question 7

Answer 7

Question 8

Answer 8

Question 9

Answer 9

C

Question 10

Answer 10

C

Question 11

Answer 11

B

Question 12

Answer 12

C

Question 13

Which symptoms require liver function tests (LFTs) to be evaluated for a patient taking allopurinol?

1. Anorexia, weight loss, or pruritus
2. Nausea, weight gain, or peripheral neuropathy
3. Constipation, headache, or taste disorders
4. Fatigue, sleep disruption, or depression

Answer 13

1. The symptoms of potentially severe hepatic dysfunction in those taking allopurinol and colchicine are anorexia, weight loss, or pruritus, and LFTs should be evaluated.

Question 14

Which drug is most appropriate for a patient with high uric acid levels who undersecretes uric acid and has adequate renal function?

1. Probenecid
2. Allopurinol and febuxostat
3. Pegloticase
4. Lesinurad

Answer 14

1. Probenecid is best for patients who undersecrete uric acid and have adequate renal function. Allopurinol or febuxostat are best for patients who overproduce uric acid.

Question 15

To minimize gastrointestinal side effects, it is recommended that bisphosphonates should be taken in which manner?

1. Before bedtime with a small amount of food to facilitate absorption
2. First thing in the morning on an empty stomach with a full 8 oz glass of water
3. Twice a day because of the short half-life
4. With juice or coffee to enhance acidity and bioavailability

Answer 15

2. This recommendation decreases the risk of esophagitis and gastric irritation and maximizes absorption in the gut. Juice can inhibit bisphosphonate absorption by up to 60% depending on the drug. Food minimizes the absorption of bisphosphonates, and a supine position increases the risk of esophagitis and reflux.

Question 16

Which recommendation should be made to a patient with a creatinine clearance (CCr) less than 30 to 35 mL/min and a serum creatinine of 5.1 regarding consideration of drug therapy with a bisphosphonate for osteoporosis treatment?

1. Bisphosphonates are safe and effective for persons such as yourself.
2. Bisphosphonates are excreted in the urine, and the recommendation is to double the standard dose.
3. Bisphosphonates are systemically metabolized, and routine liver function tests (LFTs) will be necessary.
4. Bisphosphonates are not the drug of choice for treatment of your osteoporosis.

Answer 16

4. Bisphosphonates are not recommended for patients with moderate to severe renal impairment (CCr less than 30 to 35 and serum creatinine greater than 4.9) because the drug is mainly excreted in the urine.

Question 17

Which risk factors are associated with the occurrence of gout in postmenopausal women?

1. Hypertension, renal insufficiency, and diuretic use
2. Hypothyroidism, rheumatoid arthritis (RA), and prednisone use
3. Macular degeneration, hypotension, and oral contraceptive use
4. Liver disease, osteoarthritis (OA), and NSAID use

Answer 17

1. Gout occurs almost exclusively in postmenopausal women when associated with hypertension, renal insufficiency, and exposure to diuretics.

Question 18

Steroid injections into the knee to control pain are recommended for which patients?

1. Patients requiring monthly injections
2. Patients without inflammatory symptoms
3. Patients who have failed oral and topical agents
4. Patients with limited ability to mount an immune response

Answer 18

3. Steroid injections are usually reserved for those who have failed first-line treatments, like oral and topical agents.

Question 19

The U.S. Preventive Services Task Force (USPSTF) makes which recommendation regarding the use of calcium and vitamin D supplements?

1. Supplementation is recommended for all postmenopausal women, including those residing in the community.
2. Supplementation is recommended for institutionalized adults over 65 years, or those with fragility fractures.
3. Supplementation is recommended for all with demonstrated low fall risk, without fracture.
4. Supplementation is recommended for those with osteoporosis risk and osteopenia.

Answer 19

2. The evidence supports use of supplements only in those institutionalized adults over age 65 years, or those who have demonstrated a fragility fracture.

Question 20

Gout is caused by an alteration in purine metabolism, resulting in high levels of which of these?

1. Uric acid
2. Calcium oxalate
3. Potassium
4. Dopamine

Answer 20

1. Gout is associated with hyperuricemia and deposition of urate crystals in various body tissues.

Question 21

Treatment of rheumatoid arthritis (RA) with long-term use of steroids, such as prednisolone in doses of greater than 5 mg per day, has been linked to increased risk of developing which condition?

1. Asthma
2. Chronic fatigue syndrome
3. Alopecia areata
4. Diabetes mellitus

Answer 21

4. High doses of oral prednisolone increase the risk of developing diabetes mellitus by 20 to 30 times.

Question 22

According to American Association of Clinical Endocrinologists (AACE) guidelines, dual energy x-ray absorptiometry (DEXA) scans are appropriate for which patients?

1. Women with family history of osteopenia
2. Women with known hypertension
3. Women over 40 years old who have sustained a fracture
4. All women over 50 years old

Answer 22

3. Specific recommendations include DEXA scanning for women over 65 years old, those over 40 years old with fractures, and those with primary hyperthyroidism to aid treatment decisions and monitoring for effect,

Question 23

Indomethacin (COX-1 inhibitor) is no longer the first choice for pain and inflammation relief in gout due to which factor?

1. Lack of therapeutic effect
2. Increased risk of gastric bleeding
3. Extreme expense
4. Requirement of many dietary restrictions

Answer 23

2. Although effective for pain relief, indomethacin (like other COX-1 inhibitors) increases the risk of gastric bleeding, peptic ulcers, and renal dysfunction. It is also on the Beers list.

Question 24

Serum levels of vitamin D for optimal bone health should range between which values?

1. 10 and 30 ng/mL
2. 30 and 100 ng/mL
3. 100 and 150 ng/mL
4. 150 and 250 ng/mL

Answer 24

2. Serum levels between 30 and 100 ng/mL are considered optimal for calcium balance and overall bone health. Serum levels between 10 and 30 ng/mL are too low and will produce a decrease in calcium absorption from the intestine and increase in parathyroid hormone (PTH), which may lead to bone loss and increased fracture risk.

Question 25

Which dose is the recommended maximum daily dose of calcium supplementation with vitamin D advocated by the Institute of Medicine (IOM)? 1. Up to 1,000 IU/d 2. Up to 10,000 IU/d 3. Up to 50,000 IU/d 4. Up to 100,00 IU/d

Answer 25

2. Doses of vitamin D up to 10,000 IU/d are considered safe by the IOM. Higher doses are associated with increased serum calcium levels and formation of kidney stones.

Question 26

Which population should take vitamin D supplementation to prevent occurrence of fractures? 1. Active employed adults 2. Adults who have recently retired 3. Independent adults who reside in their own dwelling 4. Individuals with a history of prior fractures, regardless of age or living conditions

Answer 26

4. Vitamin D is recommended for individuals who have a prior fracture, pose a fall risk, or have a demonstrated clinical deficiency state.

Question 27

How do rates of hip fracture and vertebral fracture among Asian American women compare with those among white women? 1. Asian American women have lower hip fracture rates and higher vertebral fracture rates. 2. Asian American women have higher hip fracture rates and lower vertebral fracture rates. 3. Asian American women have lower hip fracture rates and lower vertebral fracture rates. 4. Asian American women have higher hip fracture rates and higher vertebral fracture rates.

Answer 27

1. Asian women have lower hip fracture rates and higher rates of vertebral fracture compared with white women. Asian women consume less calcium, because 90% of Asians are lactose-intolerant.

Question 28

Which iatrogenic risk may be associated with the use of steroid injections used to relieve pain and inflammation in large joints? 1. Loss of synovial joint fluid 2. Bruising and scarring 3. Inoculation of bacteria into the joint 4. Need for repeated computed tomography (CT) scans for needle placement

Answer 28

3. Cellulitis with potential for osteomyelitis is a concern due to bacterial inoculation and suppression of the immune response.

Question 29

To reduce the risk of toxicity and rise in serum urate levels, which class of antihypertensives should be avoided in persons with hypertension taking allopurinol? 1. Beta blockers 2. Calcium channel blockers 3. Thiazide diuretics 4. Angiotensin II receptor blockers (ARBs)

Answer 29

3. Thiazide diuretics have the potential to raise uric acid levels and greatly increase the risk of toxicity.

Question 30

Persons with gout who are taking uric acid–lowering drugs should have their serum uric acid levels assessed at which interval(s)? 1. No specific recommendations for routine monitoring 2. At baseline and after 1 day of drug therapy 3. After 1 week of drug therapy 4. At baseline and after 1 to 3 weeks of drug therapy

Answer 30

4. Drug effect should be evident and normal, or approaching normal, 1 to 3 weeks after initiation of drug therapy when compared with benchmark baseline measures.

Question 31

Osteoporosis is defined as having a bone density (T score) by dual energy x-ray absorptiometry (DEXA) scan of how many standard deviations below the average adult peak bone mass? 1. 2.5 standard deviations 2. 2.0 standard deviations 3. 1.5 standard deviations 4. 1.0 standard deviations

Answer 31

1. A T score of -2.5 and below indicates significant bone loss and a sign of osteoporosis.

Question 32

To minimize the risk of osteonecrosis of the jaw, persons with cancer who have been taking IV doses of bisphosphonates or oral doses of bisphosphonates for more than 3 years, and who are planning elective invasive dental procedures, should take which action? 1. Stop bisphosphonate therapy 6 months before the dental procedure. 2. Stop bisphosphonate therapy 3 months before the dental procedure. 3. Stop bisphosphonate therapy 1 year before the dental procedure. 4. Continue taking bisphosphonates as directed before the dental procedure, but stop it post-procedure.

Answer 32

2. Although there is no evidence, it is recommended that bisphosphonate therapy be discontinued 3 months before elective dental procedure to minimize the risk of osteonecrosis of the jaw post-procedure.

Question 33

The Fracture Risk Assessment Tool (FRAX) estimates which of these? 1. The bone mass density of the femoral neck 2. The need for yearly dual energy x-ray absorptiometry (DEXA) scanning 3. The probability of bone fractures 4. The risk of falls in older woman

Answer 33

3. The FRAX predicts the 10-year probability of major bone fractures of the hip, wrist, and shoulder based on individual patient models that integrate risk with clinical factors based on bone density at the femoral neck.

Question 34

Which statement is most accurate regarding bone mineral density (BMD) in African American women when compared with white women? 1. African American women have higher BMD than white women, but African American women are more likely to die from hip fracture than white women. 2. African American women have higher BMD and are not at significant risk for hip fracture. 3. African American women have lower BMD than white women, and African American women are less likely to die from hip fracture than white women. 4. African American women have lower BMD than white women, and African American women have similar death rates to white women from hip fracture.

Answer 34

1. In general, African American women have higher BMD than white women, but are still at significant risk for osteoporosis and more likely to die from hip fracture. Seventy-five percent of African American women are lactose intolerant, avoiding milk and dairy products, which leads to poor calcium intake.

Question 35

Which foods in the "gout diet" are restricted? 1. Leafy green vegetables 2. Artificial sweeteners 3. Refined sugars 4. Bananas

Answer 35

3. The gout diet restricts intake of sodium, refined sugars, and oxalate-rich foods (liver, kidney, bacon, etc.).

Question 36

The recommended maximum daily dose of acetaminophen for a person who is suffering from moderate osteoarthritis (OA) pain and has a history of alcohol and drug use with hepatic issues is a maximum of how many grams per day? 1. 5 grams/day 2. 3 grams/day 3. 4 grams/day 4. 2 grams/day

Answer 36

2. Three grams/day is the current recommended maximum dose, especially when scheduled, rather than intermittent, dosing is utilized.

Question 37

Calcium carbonate supplements should be taken in which regimen to enhance absorption? 1. With food 2. On an empty stomach 3. One hour before bedtime with water 4. With a proton pump inhibitor

Answer 37

1. Food stimulates the release of gastric hydrochloric acid (HCl), and acidity enhances absorption.

Question 38

To relieve the acute pain of a flare of gout, which drug is the currently recommended first-line treatment? 1. Nonsteroidal anti-inflammatory drugs (NSAIDS) 2. COX-1 inhibitors 3. Opioids 4. Colchicine

Answer 38

1. NSAIDs given at the top recommended doses within the first 24 hours of the attack are the current first-line drug recommendation. COX-1 inhibitors, such as indomethacin, are associated with increased risk of gastric bleeding, peptic ulcers, and renal dysfunction; therefore, COX-1 inhibitors are not recommended as first-line treatment. Colchicine is no longer recommended because of the adverse reactions that commonly occur at doses needed to manage symptoms.

Question 38

By which primary method of action do uricosuric drugs lower uric acid levels? 1. Preventing inflammatory responses 2. Decreasing uric acid formation 3. Increasing the rate of uric acid secretion 4. Increasing renal tubular reabsorption of uric acid

Answer 38

3. Uricosuric drugs increase the rate of uric acid secretion, thus decreasing systemic uric acid levels.

Question 39

Probenecid, taken to control uric acid levels, should not be prescribed for persons allergic to which of the following? 1. Penicillin 2. Sulfa-containing drugs 3. Milk and dairy products 4. Tree nuts

Answer 39

2. Although anaphylaxis is rare, crossover sensitivity can occur with sulfa-containing drugs, requiring immediate discontinuation and treatment.

Question 40

Which warning would the APN provide to an older patient taking calcium supplements and anticoagulants (such as warfarin)? 1. Calcium supplements contain high vitamin K levels and should not be taken by older adults taking warfarin. 2. Calcium supplements contain low vitamin K levels, and warfarin doses may need to be decreased. 3. Calcium supplements contain high vitamin K levels, and no warfarin dosage change is required. 4. Calcium supplements contain high vitamin K levels, and warfarin doses may need increasing.

Answer 40

4. Older adults at risk for bone loss and fracture may benefit from calcium with vitamin D supplementation, and the high levels of vitamin K in the supplements may require an increase in warfarin to maintain a therapeutic international normalized ratio (INR).

Question 41

The prophylactic use of bisphosphonates for those with early age osteopenia should be initiated in which patients? 1. Those taking more than 7.5 mg of oral prednisone for more than 3 weeks 2. Those taking 3 mg of oral prednisone occasionally for asthma flares 3. All patients diagnosed with early age osteopenia 4. Those taking metformin for 5 years or more

Answer 41

1. Long-term use of oral glucocorticoids raises the risk of osteoporosis and fracture, and those taking 7.5 mg of prednisone or its equivalent for more than 3 weeks should be prescribed either alendronate or risedronate as a preventive measure. The diagnosis of osteopenia is no longer an automatic trigger point for treatment with bisphosphonates.

Question 42

Which recommendation is most appropriate for a person who requires chronic lowering of uric acid levels before initiation of therapy with febuxostat (Uloric)? 1. Prophylactic administration of an NSAID or colchicine 2. Strict adherence to the Dietary Approaches to Stop Hypertension (DASH) diet 3. Screening for glucose-6-phosphate dehydrogenase (G6PD) deficiency 4. Discontinuation of all other drugs

Answer 42

1. Lowering uric acid levels for up to 6 months before initiation of febuxostat (Uloric) can decrease the risk of acute gout flares.

Question 43

Colchicine, a medication used in treatment of gout, has a primary method of action that includes which of these? 1. Decreasing purine metabolism 2. Decreasing uric acid levels 3. Decreasing inflammation by uric acid crystals 4. Promoting lactic acid formation

Answer 43

3. Colchicine is prophylactic, reduces inflammation, incidence of acute attack, and relieves residual pain post-acute attack.

Question 44

Which intervention is recommended by most experts to relieve moderate pain in osteoarthritis (OA)? 1. Low dose opioids 2. NSAIDs 3. Topical salicylates 4. Acetaminophen

Answer 44

4. Acetaminophen is considered the most benign way to treat the pain of OA, either alone or in combination with a topical agent. Chronic use of NSAIDs increases renal burden, heightens risk of gastrointestinal (GI) bleeding, and increases fluid retention.

Question 45

Evaluation of which indicator is used to diagnose and signal need for treatment in Paget's disease (bone disease)? 1. Thyroid-stimulating hormone (TSH) 2. Serum calcium 3. Alkaline phosphatase 4. 25-hydroxy vitamin D

Answer 45

3. Alkaline phosphatase is a bone marker that is elevated during periods of high bone turnover, and it serves as a marker for bisphosphonate treatment when it is twice the normal level.