Bone, Joint + Rheum Flashcards
J.T. is a 68-year-old woman returning to her primary care practitioner’s office to review the results
of her most recent dual-energy x-ray absorptiometry
(DEXA) scan. Her physician reports that her lumbar spine T-score is -2.1 standard deviations (SDs)
(Z-score -1.1). The physician also reports that J.T. has
a World Health Organization (WHO) Fracture Risk
Assessment Tool (FRAX) score of 12% for major
osteoporotic fracture and 4% for hip fracture. Which
is best for J.T.’s physician to consider to preserve her
bone density?
A. Initiate high-dose vitamin D (50,000 international
units) weekly for 8 weeks and then 2000 units
daily thereafter.
B. Initiate calcium carbonate plus vitamin D (600
mg elemental plus 400 international units) twice
daily.
C. Initiate alendronate 35 mg weekly plus calcium/
vitamin D supplementation.
D. Initiate alendronate 70 mg weekly plus calcium/
vitamin D supplementation.
According to her DEXA scan results, the patient would
traditionally be classified as having osteopenia in her
lumbar spine. In many cases, this would require her to be
treated only with calcium and vitamin D supplementation. However, because her 10-year risk of a hip fracture is
greater than 3% with the FRAX tool, the NOF would consider this patient to have osteoporosis and recommend that she receive antiresorptive therapy. Of the choices, alendronate is the only agent to have antiresorptive properties, and of the two doses, 70 mg once weekly is recommended (Answer D is correct; Answers A–C are incorrect). Alendronate 35 mg once weekly is considered a prevention dose for bisphosphonates.
Correct Answer: D
D.M. is a 72-year-old woman presenting to her primary care provider for a routine follow-up. At the
visit, her provider discusses with her that she has been
taking alendronate 70 mg once weekly for the past 5
years for osteoporosis (L2/L3 compression fracture
post-fall). The physician would like to discontinue
the medication and choose a different medication to
maintain her bone mineral density (BMD). At her last
dual-energy x-ray absorptiometry (DEXA) scan, the
patient’s T-scores were -2.6 and -1.8 at the lumbar
spine and hip, respectively. These values are relatively unchanged from her baseline. She has no renal
or hepatic complications, and her metabolic profile is
within normal limits. Which is best for the patient to
replace alendronate?
A. Risedronate 150 mg by mouth once per month.
B. Raloxifene 60 mg by mouth once per day.
C. Teriparatide 20 mcg subcutaneous injection once
per day.
D. Denosumab 60 mg subcutaneous injection once
every 6 months.
The patient should restart therapy but change to a non-bisphosphonate antiresorptive agent. Using an agent for osteoporosis for this patient is important because of
her history of osteoporosis with fracture. Continuing a
bisphosphonate is an option, but the likelihood of a serious adverse event (MRONJ [medication-related osteonecrosis of the jaw], atypical femur fracture) increases with duration of bisphosphonate use. Reducing the dose would not be appropriate for secondary fracture prevention. Although
raloxifene is efficacious for secondary fracture prevention, its usefulness is more for preventing breast cancer in women at high risk, and it is not cost-effective to use routinely for fracture prevention. Denosumab is the best option for this patient because it will maintain the same efficacy as a bisphosphonate for fracture prevention (Answer D is correct; Answers A–C are incorrect). Unfortunately, we do not yet know whether the risk of serious adverse events is increased with the duration of sequenced medication use (i.e., bisphosphonate to RANKL inhibitor). An anabolic agent should be reserved for future use, more severe
disease, lack of response, and/or contraindication to antiresorptive therapies.
Correct Answer: D
C.A. is a 69-year-old woman with rheumatoid arthritis (RA). She is treated with oral methotrexate 15
mg once weekly, prednisone 10 mg once daily, and
naproxen 500 mg twice daily as needed. On returning for a follow-up with her rheumatologist, she is
instructed to decrease prednisone to 7.5 mg once daily for another 6 months. A recent DEXA scan reveals an 11% decrease in her lumbar spine since her DEXA about 1 year ago. According to the American College of Rheumatology (ACR), which approach is best to prevent osteoporosis?
A. No intervention is required because the patient is
premenopausal.
B. Administer calcium carbonate 500 mg plus cholecalciferol 400 units twice daily.
C. Administer risedronate 150 mg monthly plus calcium and cholecalciferol supplementation.
D. Administer raloxifene 60 mg once daily plus calcium and cholecalciferol supplementation.
According to the latest edition of the ACR’s guidelines for
managing glucocorticoid-induced osteoporosis, bisphosphonates should be used for patients older than 40 with moderate fracture risk (according to Z-score) if they are using 7.5 mg or more of prednisone daily for more than 6 months. Because the patient meets these criteria, risedronate 150 mg monthly plus calcium and vitamin D supplementation is warranted (Answer C is correct; Answers A, B and D are incorrect).
Correct Answer: C
F.R. is a 62-year-old woman with RA. She currently
uses etanercept 50 mg subcutaneously once weekly
and ibuprofen 600 mg every 6 hours as needed for
pain. At her latest visit to her primary care physician’s
office, she states that she will be traveling abroad later
this year and needs typhoid vaccination. Which is
most appropriate for her at this time?
A. Hold etanercept for 1 month; then vaccinate with
intramuscular Typhim Vi.
B. Start vaccination today with oral typhoid vaccine
(Vivotif).
C. Vaccinate today with intramuscular typhoid vaccine Typhim Vi.
D. She is not a candidate for typhoid vaccination.
Patients with RA receiving bDMARDs should not be
administered live vaccines such as oral typhoid. The intramuscular typhoid vaccination is an inactivated vaccine and is therefore safe to administer in patients receiving bDMARDs. It is unnecessary to hold biologics before vaccination with an inactivated vaccine (Answer D is correct; Answers A–C are incorrect).
Correct Answer: D
A.T. is a 26-year-old woman who presents to a rheumatologist after being given a diagnosis of RA. She
has symptoms in her elbows, knees, and hips and
easily becomes fatigued throughout the day. She has
difficulty dressing in the morning and has missed 10
days of work in the past 90 days because of her symptoms. Her laboratory results suggest RA, and she has no evidence of blood, liver, or kidney disease. She
is married but does not plan to have children in the
foreseeable future. Her medical history is significant
for menorrhagia, for which she has been using a lowdose ethinyl estradiol/norgestimate monophasic pill
for the past 3 years. Which medication would be best
for the patient, according to the 2015 ACR treatment
recommendations?
A. Methotrexate 10 mg by mouth once weekly plus
folic acid 1 mg once daily.
B. Leflunomide 10 mg by mouth daily.
C. Adalimumab 40 mg subcutaneously every other
week.
D. Tofacitinib 5 mg by mouth twice daily.
For this patient, the ACR 2015 treatment recommendations encourage providers to use methotrexate as a first-line agent for patients presenting within the first 3 months of diagnosis. Although leflunomide may be an option, it is recommended as an add-on to methotrexate if monotherapy insufficiently controls the patient’s symptoms. A TNF inhibitor such as adalimumab could also be an option and would have been an option for this patient using the 2012
guideline update, but it has been moved to second line,
after failure of methotrexate, for the 2015 iteration (Answer A is correct; Answers B-D are incorrect). The JAK inhibitor tofacitinib is recommended for disease-naive patients (less than 6 months) whose second-line measures fail or for disease-experienced patients (more than 6 months) in whom at least a TNF inhibitor fails.
Correct Answer: A
J.P. is a 34-year-old man with a medical history significant for psoriasis. For the past 15 years, he has
been treated successfully with hydrocortisone cream
and moisturizers, rarely requiring oral systemic corticosteroids. Today, he presents to his primary care
physician’s office with a worsening joint pain in his
hands and elbows. He says the pain is minimal (2/10),
but annoying. He has been receiving sufficient pain
relief from naproxen 500 mg twice daily as needed
but wonders if he could be doing more. On physical
examination, he has actively inflamed joints in his left
hand. His physician performs some radiographic evaluations, which reveal signs of axial disease, and the physician determines that J.P.’s symptoms are likely caused by psoriatic arthritis (PsA). Given the patient’s presentation, which is the best regimen for treating his arthritic symptoms?
A. Continue naproxen 500 mg twice daily as needed.
B. Initiate sulfasalazine 500 mg twice daily.
C. Initiate etanercept 50 mcg twice weekly.
D. Initiate etanercept 50 mcg twice weekly plus sulfasalazine 1000 mg three times daily.
According to the ACR and GRAPPA, patients with minimal to no functional limitations from PsA should be treated only with NSAIDs or other analgesics. When the symptoms progress to moderate severity and affect the patient’s activities of daily living, or when the symptoms do not respond to simple analgesics, providers should consider adding either a DMARD (e.g., sulfasalazine) or a biologic agent (e.g., etanercept). Combination DMARD and biologic agent should be reserved for patients with severe disease or for those whose condition does not respond to either agent alone (Answer A is correct; Answers B-D are incorrect).
Correct Answer: A
J.O. is a 76-year-old woman with a history of type 2
diabetes and chronic stable angina (medically managed). She has bilateral knee osteoarthritis (OA) pain that has not been sufficiently controlled with physical therapy or acetaminophen 1000 mg every 6 hours. She cannot perform many activities of daily living because she requires a walker, which considerably impairs her mobility. Which regimen is best to help alleviate the patient’s chronic pain?
A. Meloxicam 7.5 mg once daily.
B. Topical diclofenac 1% gel.
C. Ketorolac 10 mg every 6 hours.
D. Morphine sulfate extended release 15 mg twice
daily
For this patient, the next best choice for pain relief is topical diclofenac 1% gel. The ACR 2012 guidelines do not recommend the routine use of opiate analgesia for OA pain. In addition, given her history of ischemic heart disease, she should avoid using meloxicam or oral diclofenac because of an FDA report regarding NSAID use and risk of CV events. Although diclofenac gel is an NSAID, its topical application limits the amount of systemic absorption and possibly systemic adverse events (Answer B is correct; Answers A, C and D are incorrect). Patients who use topical NSAIDs are at a higher risk of dermatologic reactions than those who use systemic NSAIDs.
Correct Answer: B
T.Q. is a 29-year-old woman without obesity who has
been treated with hydroxychloroquine for systemic
lupus erythematosus (SLE) for the past 3 years. Her
current dose is 400 mg once daily (about 5.4 mg/kg).
She speaks with her pharmacist, who asks whether she
has been receiving regular ophthalmologic screenings
for patients chronically treated with hydroxychloroquine. The patient has never had her eyes checked.
Which would be the best recommendation for this
patient’s current and future ophthalmologic screening?
A. Initial screening now and then every 5 years.
B. Initial screening now and then annually thereafter.
C. Initial screening now and then annually starting
at year 5.
D. Initial screening now and then every 6 months
starting at year 5.
Even though the patient has used hydroxychloroquine for less than 5 years, her current daily dose is greater than
5 mg/kg/day, placing her in a higher-risk category for
hydroxychloroquine-related ocular complications. People
in the major risk category should have a baseline, followed by annual, funduscopic examination. (Answer B is correct; Answers A, C and D are incorrect)
Correct Answer: B
R.V. is a 42-year-old woman with a significant history
of depression and schizophrenia. Her current drug regimen is ziprasidone 40 mg twice daily and selegiline transdermal 6 mg/24 hours. Her symptoms are consistent with fibromyalgia syndrome, but she has been reluctant to start treatment until now because she was afraid it would interfere with her other mental health medications. However, the symptoms have worsened during the past 6 months, and she now asks to begin therapy. Which medication would be the best for R.V. to begin taking?
A. Nortriptyline 25 mg once daily in the evening.
B. Gabapentin 100 mg twice daily.
C. Pregabalin 75 mg twice daily.
D. Duloxetine 60 mg once daily
The patient would best begin treatment with pregabalin 75 mg twice daily. Although all the medications listed are appropriate for treating fibromyalgia syndrome, several issues need to be considered. Nortriptyline and duloxetine would create a significant drug-drug interaction with
transdermal selegiline because it inhibits both monoamine oxidase A and monoamine oxidase B (nonselective), most likely resulting in hypertensive crisis and/or serotonin syndrome. However, this is not true for oral selegiline. Oral selegiline at a dose of 5 mg twice daily maintains specificity to inhibit monoamine oxidase B, which is primarily responsible for monoamine oxidase activity in platelets
and the brain. Because of this selectivity, when used at
approved doses, oral selegiline and other serotonergics pose no increased risk of serotonin syndrome. The gabapentin dose is too low for the patient and would most likely not have a clinically significant change in her symptoms. The target dose for gabapentin for fibromyalgia is 1800–2400 mg daily (divided three times). (Answer C is correct; Answers A, B and D are incorrect)
Correct Answer: C
L.L. is a 58-year-old man with chronic tophaceous
gout and stage 4 chronic kidney disease (CKD). He
reports only taking over-the-counter (OTC) ibuprofen for gout in the past but states he was told to stop
because it “hurt his kidneys.” He states that the tophi
sometimes bother him and that he has two or three
attacks per year. The patient has 10–12 alcoholic
drinks a day and regularly consumes a lot of meat proteins. In addition to dietary counseling, which therapy is best to decrease tophi and prevent gouty attacks in this patient?
A. No therapy is required until he has two or more
gouty attacks in a 12-month period.
B. Administer allopurinol 50 mg once daily, slowly
titrated over the next few months.
C. Administer allopurinol 300 mg once daily, slowly
titrated over the next few months.
D. Administer colchicine 0.6 mg three times weekly.
The patient has CKD, thereby limiting the choice of medications and doses that can be used to prevent recurrent gouty attacks. The patient is a candidate for gout prevention and treatment of hyperuricemia. The number of attacks per year does not factor in when initiating therapy. Colchicine does not affect tophi formation. Xanthine oxidase inhibitors (allopurinol first line) are the drug of choice for patients with tophi. The ACR guidelines state that in patients with stage 4 CKD or worse, allopurinol therapy can be initiated at 50 mg/day, increasing the dose every 2–5 weeks to achieve the desired uric acid concentrations; doses greater
than 300 mg/day are allowed but with appropriate patient
education and monitoring for toxicity (Answer B is correct;
Answers A, C and D are incorrect)
Correct Answer: B
List drugs that cause osteoporosis
1.Antiepileptics
2.Immunosuppressant (cyclosporine)
3.Lithium
4.PPI
5.Systemic steroids
6.SSRI
7.excessive thyroid hormone supplementation
8.TCA
9.Warfarin or long term use heparin
10.TZD
which drugs and conditions in women may increase risk for osteoporosis
Medroxyprogesterone use
Excessive vitamin A intake
GI malabsorption syndrome
Parent with osteo
drug and condition specific factors for men to get osteo
Loop diuretic use
Gonadotropin releasing hormone agents (prostate cancer)
Psoriasis
T-score of 0 or 1 SD equals what
Normal BMD
T-score of 1-2.5 SDs below the mean value means the pt has
Osteopenia
T-score greater than 2.5 SDs below the mean value means
Pt has osteoporosis
What is the recommendation when pt has FRAX score at hip = >3
Give treatment doses antiresorptive agent such as bisphosphonate
A FRAX score => 20 means
Give treatment doses antiresorptive agent
When a patient’s z-score is greater than 2 SD below the mean what does this
Accelerated bone loss unrelated to menopause or aging
Describe the clinical diagnosis of osteoporosis
Patient has a fragility fracture at the spine ,hip ,wrist, humerus, rib or pelvis OR
T score -2.5 or less SDs at any site measured by dexa
Calcium carbonate is what % elemental
40%
Calcium citrate is what % elemental
21%
Calcium citrate comes in what strength milligram tablets
200 to 315mg
When evaluating what calcium supplement to give think about STEPS, what does the acronym mean
S for safety
T for tolerability
E for efficacy
P for preference (pearls)
S for simplicity
