Bone/Joint & Rheum

Question 1

Calcium for prevention of fracture

Answer 1

Adults > 50 years: Calcium 1000-1500mg (elemental) daily from diet or supplementation

Question 2

Vitamin D for prevention of fracture

Answer 2

Adults > 50 years: 800-1000 units/day from diet or supplementation

Question 3

T-scores

Answer 3

Normal: 0-1 SD below mean
Osteopenia: 1-2.5 SDs below mean
Osteoporosis: > 2.5 SDs below the mean

Question 4

Bisphosphonates

Answer 4

Alendronate, ibandronate, risedronate, zoledronic acid*
All for prevening vertbral fractures, *for those preventing nonvertebral and hip fractures
Resolve low calcium before initiating, caution in renal impairment, osteonecrosis of jaw?, atypical femur fracture in those using > 5 years?
GI tolerability issues - administration instructions

Question 5

Estrogen replacement therapy

Answer 5

For reduced risk of vertebral and nonvertebral fractures
Risk of HRT exceeds the benefits (associated with CHD, stroke, breast cancer, VTE)
Acts in conuunction with bisphosphonate better than either agent alone

Question 6

selective estrogen-receptor modulator (SERM)

Answer 6

raloxifene, lasofoxifene
For increased BMD, reduced incidence of vertebral fractures
increased risk of fatal stroke in women with CHD and increased risk of VTE
Also used to prevent invasive breast cancer

Question 7

teriparatide

Answer 7

biosynthetic parathyroid hormone (injection)
for decreased vertebral fractures in postmenopausal women; increasing vertebral and hip BMD; preventing BMD loss & vertebral fractures in chronic corticosteroid use
Avoid in pts: alkaline phosphatase elevation, open epiphyses, paget dx, prior skeletal radiation
associated w/osteosarcoma in rats
ADE: flulike, hypercalcemia
diminished efficacy if used w/bisphosphonate; add a bisphos after discontinuing teriparatide

Question 8

denosumab

Answer 8

RANKL antagonist for decreased vertbral, nonvert, and hip fractures; increases BMD in hip and lumbar spine
ADE: cellulitis, osteonecrosis of jaw, eczema, flatulence
NICE of UK recommends for those at risk of osteoporotic fracture unable to adhere to or tolerate a bisphosphonate
Subq every 6 months

Question 9

calcitonin

Answer 9

For reduced incidence of vertebral fractures; beneficial effects on BMD
ADE: anaphylactoid rxns w/injection
Inferior to alendronate
may help relieve bone pain w/fractures but not an indication to choose as the primary tx
Nasal (one nostril, alternating) and injection

Question 10

NSAIDs for RA

Answer 10

Think about GI and CV risk
reduce joint pain and swelling, equally effective but diff pts will respond differently
Celecoxib- fewer GI ade but equally effective
misoprostol (decrease GI ulceration risk) or PPI (decrease nonulcerative sxs)
trial 14-28 days then try another NSAID if pt doesn’t respond (before concluding therapeutic failure)

Question 11

Corticosteroids for RA

Answer 11

Short-term, low-dose (less than 15mg/day) effective for flare-ups
long-term low-dose (< 10mg/day) reduces joint destruction & increases liklihood of remission
higher doses may be warranted to treat severe or advanced dx
limit intra-articular inj to every 3-4months
start calcium and vit d supplementation in all pts

Question 12

methotrexate

Answer 12

synthetic DMARD
effective for RA (first line DMARD); can change to subq if inadequate response to oral
Add a folic acid supplement to decrease ADE
once weekly, oral or subq
CI: preg & lactation
increase malignancies
avoid in: crcl < 30; platelet < 50,000, wbc < 3000, liver transam > 2x upper limit; avoid concurrent NSAIDs

Question 13

leflunomide

Answer 13

Synthetic DMARD
comparable to methotrexate; may be added to methotrexate but at risk of hepatotoxicity
*use as alt for pts unable to tolerate or not responding to methotrexate
Risks: SJS, malignancy
CI: pregnancy (fathering); liver dx

Question 14

sulfasalazine

Answer 14

synthetic DMARD
modifies rheumatic dx; alternative for pregnancy
Preg cat B
Avoid in: platelet < 50,000, elevated liver transam, hepatitis

Question 15

TNF inhibitors

Answer 15

First-line Biologic DMARD
adalimumab, certolizumab pegol, etanercept, golimumuab, infliximab
radiolographic outcomes are superior to synthetic DMARDs
combo with methotrexate yields better outcomes than TNF as monotherapy
generally recommended after insufficient response to synthetic DMARDs
infliximab should be used only in combo w/methotrexate
subq dosing (frequency depends on agent)

Question 16

abatacept

Answer 16

biologic DMARD
option for mod-severe dx for > 6 months OR those with poor prognostic features who are non-responders to methotrexate or another synthetic DMARD
typically used after failure of a TNF inhibitor
do not use in combo with other biologic DMARDs
combo with methotrexate results in higher rates of remission than methotrexate alone
ADE: pulmonary and infectious
IV or subq

Question 17

rituximab

Answer 17

biologic DMARD
monotherapy or with methotrexate; use after failure of TNF inhib
avoid live vaccines 3 months before or during tx
consider apap and antihistamine before infusion

Question 18

tocilizumab

Answer 18

biologic DMARD
for pts w/inadequate response to TNF inhib
used in combo with methotrexate

Question 19

anakinra

Answer 19

biologic DMARDs
not as effective as TNF inhibs, not in guidelines d/t limited data
no live vaccines
subq

Question 20

topical applications for OA

Answer 20

capsaicin: should reduce pain in ~2 weeks
NSAIDs: short-term efficacy but insufficient info on long-term (> 12 weeks) use; recommended over oral in pts > 75

Question 21

NSAIDs & APAP for OA

Answer 21

first-line for pain
NSAIDs more effective than APAP but less favorable ADE profile
APAP max dose 4g/day
pt w/hx of GI ulcer: cox-2 inhib or NSAID with PPI
pt w/GI bleed in past 12 months: COX-2 inhib with PPI

Question 22

controlled opioid antagonists for OA

Answer 22

should not be used routinely; limit to severe pain uncontrolled on APAP or NSAIDs

Question 23

glucosamine & chondroitin

Answer 23

delayed onset, not for immediate pain relief
trials are small and variable quality
not routinely recommended by ACR

Question 24

tramadol

Answer 24

non-controlled opioid analgesic

alternative for pts with inadequate OA pain relief from APAP/NSAID

Question 25

NSAIDS for acute gout pain

Answer 25

all are equally effective

continue tx until sxs subside

Question 26

colchicine

Answer 26

for acute gout pain
slower pain relief than NSAIDs
dose adj for CrCl < 30
ADE: hematologic, GI
doses > 4mg/day may cause organ failure & death
*can be used with probenecid for first 6 months to prevent gout indcued by urate-lowering therapy

Question 27

corticosteroids for acute gout

Answer 27

good option if renal insuff
prednisone is equal in efficacy to NSAIDs for reducing pain & discomfort
intra-articular for large joint involvement; benefits in 48 hours

Question 28

allopurinol

Answer 28

first line xanthine oxidase inhibitor for prevention of gout attack
renal dose adj

Question 29

febuxostat

Answer 29

xanthine oxidase inhib; better uric acid concentration reduction than allopurinol but no more effacious for preventing gout flares and considerably more expensive
CI: azathiprine, mercaptopurine, theophylline
higher incidence of CV events than allopurinol
*no renal adj

Question 30

probenecid

Answer 30

uricosuric agent
ineffective even in mild renal insuff
start w/low dose to prevent precipitation of gout attack
avoid in uric acid kidney stones
many drug interactions

Question 31

pegloticase

Answer 31

infusion every 2 weeks; give gout flare prophylaxis with NSAID or colchicine for 1 week before infusion and at least 6 months after
CI: G6PD deficiency
BBW: anaphylaxis, infusion rxns (risk increased when uric acid > 6mg/dL)

Question 32

rasburicase

Answer 32

uricolytic agent; FDA approved for tumor lysis syndrome but may reduce tophi & uric acid concentrations in pts with gout

Question 33

TX of Osteopenia

Answer 33

T-score -1 to -2.5 and FRAX hip fracture risk > 3% or major fracture risk > 20%: calcium + vit d + bisphosphonate

if don’t reach those FRAX scores, then just calcium + vit D

Question 34

Tx of Osteoporosis

Answer 34

T-score -2.5 or less: calcium + vit d + bisphosphonate