Chapter 10-16 Nov 23 Flashcards
Question
Answer
Q1: What’s the maximum dose of methotrexate a person can take a week?
- Severe Crohn’s disease (max 15mg weekly)
- Moderate to severe active rheumatoid arthritis (max 20mg
weekly) - Severe active rheumatoid arthritis (max 25mg weekly)
- Severe psoriasis
(max 30mg weekly under specialist supervision)
Q2: What is not recommended for osteoarthritis?
- Glucosamine,
- chondroitin, and topical rubefacients
- Intra-articular preparations of hyaluronic acid are available for osteoarthritis of the knee but are also not recommended.
Q3: What is rheumatoid arthritis?
Rheumatoid arthritis is a chronic systemic inflammatory disease
That causes persistent symmetrical joint synovitis
(inflammation of the synovial membrane)
typically of the small joints of the hands and feet.
Q4: What are the main symptoms of rheumatoid arthritis?
- Joint pain Stiffness,
- swelling,
- tenderness
- heat in the affected joints.
- Lasts for > 30 minutes.
Rheumatoid nodules Symmetrical: affects both sides Non-specific symptoms: malaise, fatigue, fever, and weight loss.
Q5: What does DMARD stand for?
Disease modifying anti-rheumatic drugs
Q6: What are the 4 most common drugs used in rheumatoid arthritis?
- Methotrexate,
- Azathioprine,
- Ciclosporin,
- Sulfasalazine
Q7: What are the less commonly used drugs in rheumatoid arthritis?
- Sodium aurothiomalate (Gold),
- Leflunomide,
- Penicillamine Antimalarilas
(hydroxychloroquine/chloroquine)
Q8: If a patient starts on a DMARD, could it affect their NSAID dose?
Yes, it does
1. When used concomitantly with a DMARD, an NSAID should be used at the lowest effective dose.
- This is to reduce the risk of interactions, side effects and toxicity.
Q9: What are the main aims for treating RA with DMARD’s?
Stop it from getting worse
Reduce the symptoms of the disease
Q10: What is osteoarthritis?
Joint problem
Symptoms experienced only when the joint bears weight.
One sided
Morning stiffness lasts < 30 minutes
Q11: What are the main symptoms of osteoarthritis?
- Swelling of the joint
- Morning stiffness < 30 minutes
- Pain of the joint
- Grating or crackling sound of the joint when moving
Q12: What are the main drugs used to treat osteoarthritis?
- Paracetamol is always the 1st option
- If it affects the hands or need’s anti inflammatory drugs, we use
capsaicin
or a topical NSAID. - Oral NSAID
Q13: If patients are already taking aspirin for pain due to osteoarthritis, what can be given after and why?
- opiate
- never give aspirin in combo with another NSAID
- Risk of GI bleeding, ulcers,
- renal damage and other side effects.
Q14: What lifestyle measures should be taken by people who have osteoarthritis?
- Lose weight
- Exercise
- Wear comfortable shoes
- Always maintain good posture
Q15: Which group of people should not take glucosamine?
- not recommended to treat osteoarthritis
- no solid evidence to prove it does anything.
- It should never be used in people allergic to shellfish
- It should be avoided in pregnancy
Q16: What is Gout and what are the key symptoms?
- A type of arthritis that affects the joints in the hand and feet
- Due to a build-up of urate crystals in these joints
- More common in men
- The key symptoms include:
- Swollen joints, especially hands and feet
- Tenderness
- Redness
- Warmth
- Pain * Needle like crystals forming in the joints
Q17: What are the risk factors for gout?
- Male gender
- Alcohol
- Organ meats
**Drugs**
:
* thiazide diuretics, loop diuretics,
* ethambutol,
* pyrazinamide,
* isoniazid and cytotoxics.
Recent injury or surgery of the joint * Current health problems: high blood pressure, kidney failure, diabetes and high cholesterol
Q18: What is used for the treatment of an acute gout attack?
- Colchicine or
- High dose NSAID is an alternative. Naproxen is a good choice. *
**Colchicine**
MHRA
warning
:
fatal toxicity if overdose happens.
Q19: What’s used for the long term management of gout?
- Allopurinol always 1st line
- Febuxostat if allopurinol not suitable
- Sulfinpyrazone or benzbromarone
(specialist after no success with allopurinol or febuxostat)
Q20: What’s the main CI’s of colchicine?
Any kind of blood disorder
Pregnancy
EGFR < 10
Q21: What dose of colchicine should be used for gout?
Comes is 500mcg strength *
1 tablet (500mcg) 2-4x a day * Maximum 3 day’s worth of treatment *
Maximum supply: 12 tablets.
Q22: What’s the maximum number of colchicine tablets to be used for gout?
**12 **
Always remember 12
Q23: Which drugs should be avoided when on colchicine for gout and why?
Avoid the enzyme inhibitors:
GAVID SICKFACES.COM *
Enzyme inhibitors cause colchicine toxicity, because they raise colchicine levels in the body. *
Avoid anything that causes diarrhoea (CALM D) *
Avoid the liver toxic drugs. *
Statins should be avoided due to muscle death
Q24: What’s the main MHRA warning on febuxostat?
- Hypersensitivity reactions such as anaphylaxis
- SJS (steven johns syndrome).
If this happens, stop
and see GP
*
Increased risk of cardiovascular death in patients with history of cardiovascular problems.
Q25: What’s myasthenia gravis and what are the main treatments for it?
Muscle weakness especially of the eye muscles *
Main treatments:
1. Neostigmine
2. Pyridostigmine
Q26: What’s the main advice regarding treatment cessation of Baclofen for muscle spasms?
**don’t stop abruptly **
can cause
1. hyperthermia,
2. hallucinations and
3. worsen the spasms *
Always reduce the dose gradually over 1-2 week intervals.
Q27: What can be used as an alternative to baclofen for muscle spasms?
Methocarbamol
Q28: Give examples of NSAID’s?
- High dose aspirin *
- indomethacin *
Anything ending with the following:
Profen
* Fenac *
Fenamate
fenamic
acid
Oxicam
* Proxen
* Coxib
Q29: What’s the main counselling points for NSAID’s?
- Never take more than TDS
- Always take it with food or full stomach
Report any warning signs such as:
1. Dark stools
2. coffee coloured vomit *
3. Worsening of asthma *
4. GI bleeding *
5. Anemia *
6. Weight loss and unable to swallow *
7. Swollen ankles and fee
t *
Any patients with any kind of arthritis or over 45 should be given PPI
with it.
Q30: What can NSAID’s worsen the symptoms of?
- Asthma:
for NSAIDS this is a caution or a CI depending on the NSAID
NSAIDS can also worsen the symptoms of heart failure as
NSAIDS are contraindicated in heart failure
Q31: What are the selective and nonselective NSAIDS and what’s the difference?
Selective NSAIDs: less GI side effects but they have more CV effects (coxibs)
Non Selective: more GI side effects but less CV effects (Ibuprofen)
Q32: Which NSAIDS are associated with a higher CV risk?
Selective NSAIDs are always associated with more CV risks. *
Higher doses of NSAIDs are also associated with CV risk. *
Coxibs
have the highest risk
and profens
have the lowest risk.
Q33: What are the main CI and side effects of NSAID’s?
C/I:
Active GI bleeding,
P+BF, heart failure,
heart disease
IBD.
S/E:
GI ulcers, GI bleeding and sensitivity reactions.
Q34: What are the main uses of NSAID’s?
- Pain *
- Fever (pyrexia)
- Rheumatic disease
- Muscle pain.
- Acute Gout attacks
Q35: What are the ibuprofen doses for children 3 months to 12 years?
(See detailed dosing table)
Q36: What are the paracetamol doses for children 3 months to 12 years?
- 3 months to 6 years we always use 120mg/5ml
- For 6 years and above we use 250mg/5ml.
- Remember the dose in ml always increases by
2.5ml and the age intervals do overlap - Remember it’s max 4x a day
- Use the amount in ml to calculate mg
- Remember that it’s 3 months, 6 month and 24
months = 2.5ml and 5mll - Remember that the ages 2 years and above
increase in increments of 2 years. 2-4 years (7.5ml)
and 4-6 years (10ml). - Remember that the 6-8 years (5ml), 8-10years
(7.5ml) and 10-12 years (10ml) - Practice drawing the table on the right and you’ll be
fine.
Ages 3 months-6 years
(120mg/5ml)
3-6 months 2.5
6-24 months 5
2-4 years 7.5
4-6 years 10
Ages 6-12 years (250mg/5ml)
6-8 5
8-10 7.5
10-12 10
(See detailed dosing table)
Q37: What dose of chloramphenicol would you give to someone with bacteria conjunctivitis?
- 1 drop every 2 hours in the affected eye for 2 days
- 1 drop every 4 hours for the remaining 3 days
5 day course
Q38: What are the main counselling points regarding the use of eye drops in general?
- Always wash your hands before using them.
- Make a pocket with your eye lid and squeeze a drop in there.
- Blink and keep the eye closed for 2 minutes
- If you want to use more than 1 eye drop, you need to wait for 5
minutes. You can’t use more than 1 drop at the same time. - Keep the dropper clean and never touch your eye with it.
- Don’t drive until vision is okay
- Throw the drops away after 28 days.
(See detailed counseling points)
Q39: What eye drops are used for allergic conjunctivitis?
Antihistamine eye drops
- Sodium cromoglycate
This is not an infection so they won’t use antibiotics.
Q40: What’s used for the prevention and treatment of inflamed eyes not a result of infection?
NSAID eye drops such as diclofenac
Q41: What is blepharitis and what are the key symptoms to look for?
Blepharitis is often caused by staphylococci.
- swollen, sore eyelids
- itchy eyes eyelids
- a gritty feeling in the eyes
- flakes or crusts around the roots of the eyelashes
- eyelids sticking together in the morning when you wake up
- It’s not usually serious and can often be treated by washing your eyelids every day.
Q42: What are the main treatments for blepharitis?
- First line treatment is just good eye hygiene by giving it a good wash
- Good eye hygiene should be carried out 2x a day and then once daily when the symptoms are easing.
- Is it’s not cured by a good eye wash use treatments such as:
- Chloramphenicol
- Propamidine isethionate
- Dibrompropamidine isethionate
- Patients should avoid any eye paints and mascara as it can make it all worse.
(See detailed treatments)
Q43: What are the main lifestyle points for people with blepharitis?
- Clean your eyelids twice a day with an eye pad or cotton bud or wool, Soak a clean
flannel or cotton wool in warm water and place it on your closed eyelid for 5 to 10
minutes. - Gently massage your eyelids for around 30 seconds.
- Clean your eyelids using cotton wool or a cotton bud. It might help to use a small amount
of baby shampoo in water. Gently wipe along the edge of your eyelids to remove any flakes or crusts. - then once a day as your symptoms improve continue to clean your eyes, even if your
symptoms clear up - Avoid eye make up and mascara as that makes it worse.
Q44: What is conjunctivitis and what are the key symptoms to look for?
- Inflammation of the conjunctiva
- Various causes: Bacteria, Viral, Allergy Symptoms and Diagnosis:
- Bacterial: it can either affect 1 or both eyes. Yellow discharge and
self limiting. May need antibiotics if it last longer than a week. - Viral: always affects both eyes, gritty, watery discharge, and other
cold and flu like symptoms as well. - Allergy: both eyes affected, irritation, watery discharge and
discomfort.
Q45: What are the main treatments for conjunctivitis?
- For bacterial: Chloramphenicol, propamidine isethionate
(safe in all ages and for pregnancy and breastfeeding)
- For allergic: sodium cromoglicate
- For viral: artificial tears and simple pain killers
- Refer if:
- Vision affected
- Glaucoma
- No improvement after 2 days
- P+BF
- Photophobia
- Eye pain
- Dry eye syndrome
Q46: What are the main lifestyle points for people with conjunctivitis?
- Wash hands after touching eye,
- Conduct good eye hygeine
- Do not share towels/pillows,
- Avoid wearing contact lenses during treatment
- It’s self limiting so piss off. No antibiotics.
Q47: What is glaucoma?
- Glaucoma is a group of eye disorders characterised by
a loss of visual field associated with pathological
cupping of the optic disc and optic nerve damage. - It is generally associated with high intraocular pressure
(IOP), although it can still occur when the IOP is within
range.
Q48: What drugs are used to treat glaucoma?
- The aim of treatment: to control intraocular pressure to prevent the development
or progression of glaucoma, and subsequent visual field damage or sight loss.
The classes of drugs: - Topical prostaglandin analogue: latanoprost, tafluprost, travoprost, or bimatoprost.
- Topical beta blocker: betaxolol, levobunolol, timolol.
- Carbonic anhydrase inhibitors: brinzolamide, dorzolamide.
- Topical sympathomimetic: apraclonidine (unlicensed) or brimonidine.
- Topical miotic: pilocarpine (unlicensed)
(See detailed list of drugs)
Q49: What are the main side effects of antiglaucoma drugs?
- The side effects of these drugs are usually local although
systemic SEs might occur with certain eye drops. - Common SE seen:
- Eye discomfort,
- Eye inflammation,
- Eye disorders.
- Vision disorders
- It is best to consult literature for each specific drug.
(See general side effects)
Q50: What is the most common preservative in eye drops?
Benzalkonium chloride
Q51: What is anterior uveitis and what is used to treat it?
- Anterior uveitis is an inflammation in the middle layer of the eye.
- Symptoms: red, sore & inflamed eye; blurred vision, sensitivity to light, small or irregular-shaped pupil.
Drug Treatment:
Topical antimuscarinics: E.g. atropine,
cyclopentolate, homatropine.
Anti-inflammatory: for treating inflammation.
Q52: What is subconjunctival haemorrhage, what used to treat it and when should you refer?
- This is described as when the tiny blood vessels between the conjunctiva
and sclera burst. Could be all of the eye or only certain parts. - No treatment is required as will fade away generally within 2 weeks.
- Refer if patient is on anticoagulants, also very high blood pressure.
Q53: What are the key symptoms of keratitis and what are the treatments?
- Keratitis is an infection that affects the cornea.
- Symptoms: eye pain, sensitivity to light, red eye, watery eye, and blurred vision.
- Treatment is dependent on cause of infection (bacterial/fungal/viral).
(See detailed description and treatment)(See detailed description and treatment)
Q54: What are the universal red flag symptoms of eye problems?
- Pain in the eye (different from eye discomfort or itching)
- Photophobia
- Poor vision
- Pus discharge from cornea
- Pupil abnormality
- Foreign body in the eye
(See detailed list of red flag symptoms)