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Pre-reg > Chapter 10- Muscoskeletal System > Flashcards

Chapter 10- Muscoskeletal System Flashcards

1
Q

What’s used for pain relief in osteoarthritis and soft tissue disorders

A

Paracetamol first line

Topical NSAID or capsaicin considered especially in knee or hand osteoarthritis

+- Oral NSAID

Opioid if still not adequate

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2
Q

When should opioid be considered before NSAID in osteoarthritis

A

If the patient is on low dose aspirin

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3
Q

What’s rheumatoid arthritis

A

Chronic systemic inflammatory disease that causes persistent inflammation of the synovial joint (typically the small joints of the hands and feet)

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4
Q

What worsens rheumatoid arthritis

A

At rest or periods of inactivity
Swelling
Tenderness
Heat in the affected joints

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5
Q

What do DMARDs include

A 
Methotrexate 
Azathioprine 
Ciclosporin 
Antimalarials 
Leflunomide 
Cytokines modulators
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6
Q

When can you consider doing when starting DMARD for newly diagnosed rheumatoid arthritis

A

Short term bridging with with a corticosteroid as dmards have a slow onset of action and can take 2-3 months to take effect

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7
Q

Of the DMARDS which are preferred and why

A

Methotrexate or sulfanazine

They are better tolerated

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8
Q

What should be given in newly diagnosed active rheumatoid arthritis

A

Combination of DMARDS
(MTX + other)

And short term corticosteroids

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9
Q

How is Gold used as a suppressing drug

A

It’s given as sodium aurothiomalate
Given by deep IM injection and the area gently massaged
If effective treatment continued for 5 years
If not improvement in 2 months alternative treatment should be given

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10
Q

When should gold treatment be discontinued

A 
Bleeding disorder 
GI bleeding 
Ulcers 
Proteinuria
Rash and pruritis
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11
Q

How long would penicillamine treatment take to work and how long should you give it before discontinuing if no improvement

A

6-12 weeks

1 year

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12
Q

What is used to treat acute gout attacks

A

High dose NSAID (not aspirin)
Colchicine is an alternative
Corticosteroids if resistant to other treatment

Allopurinol, febuxostat and uricosuric are not indicated in attacks as they can exacerbate it

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13
Q

Why is colchicine preferred over NSAIDs in heart failure

A

Unlike nsaid it does not induce fluid retention

Given to patients on anticoagulation

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14
Q

How is long term gout managed

A

Xanthines oxidase inhibitors (allopurinol, febuxostat)

Or uricosuric drug- sulfapyrinazone (increases excretion of Uris acid in the urine

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15
Q

When are management drugs for gout started?

A

1-2 weeks after the attack has settled

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16
Q

How is hyperuricaemia treated?

A

Febuxostat

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17
Q

How long is gout management treatment for in recurrent attacks

A

Indefinitely to prevent further attacks of gout by correcting hyperuricaemia

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18
Q

What can be being for long term management in resistant gout

A

Allopurinol with sulfinpyrazone

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19
Q

MHRA alert for feboxustat

A

Rate but serious case of hypersensitivity (stevens Johnson syndrome)
And acute anaphylactic shock

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20
Q

What increases the chance of developing gout

A

Renal impairment

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21
Q

in patients regularly taking allopurinol and experiance a gout attack should they stop?

A

No carry on the allopurinol

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22
Q

When should allopurinol be withdrawn

A

If the patient develops a rash

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23
Q

Apart from gout, when else could allopurinol be taken

A

Hyperuricaemia associated to cytotoxic drugs

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24
Q

What can be used in myasthenia gravis

A

First line- Anticholinestrase (eg: neostigmine)

Immunosuppressant therapy

Corticosteroids

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25
Q

Side effects of anticholinestrate used is myasthenia gravis

A

Muscarinic side effects:
Sweating
Excessive salivation
Bradycardia

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26
Q

When are muscle relaxants used and which ones can be used

A

Used for chronic muscle spasm and spasticity with MS or neurological damage.

Baclofen depresses the CNS
Cannabis can be used for spasticity in MS
Diazepam can also be used

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27
Q

What’s the purpose of anticholinestrase

A

To enhance neuromuscular transmission in voluntary and involuntary muscle

Prolong action of Ach

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28
Q

How can the acetylcholinestrase adverse effects be antagonised

A

Atropine

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29
Q

What can be given for nocturnal leg cramps

A

Quinine

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30
Q

What severe adverse effects has the use of cytokines modulators been associated with

A

Infection risk such as:
Tuberculosis
Septicaemia
Hepatitis b reactivation

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31
Q

Why should allopurinol be taken with a full glass of water

A

To prevent kidney stone and promote uric acid excretion

Excreted via the kidneys

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32
Q

Counselling for allopurinol

A

May take several months to work
Increase fluid intake to prevent kidney stones
Not for acute attacks (prevent long term)

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33
Q

Counselling points for baclofen used as a muscle relaxer

A

Dizziness is expected
No alcohol
Do not stop abruptly (slowly reduce dose over 1-2 weeks)

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34
Q

Initiation of gout prevention may precipitate a gout attack, what can you do to prevent this

A

Give allopurinol as the prevention but give colchicine/ NSAID for 1 month after hyerpuriceamia is corrected

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35
Q

What provides analgesic affect in gout

A

NSAID

36
Q

What’s the first choice for pain and stiffness from inflammation

A

NSAID

37
Q

How long does it take for NSAIDs to reach its full analgesic and full inflammatory effect

A

Analgesic reached in 1 week
Inflammatory reached in 3 weeks

Mild- moderate pain relief with first dose

38
Q

How do NSAIDs work

A

Reduce production of prostaglandin by inhibiting cyclooxygenase (COX)

39
Q

What’s an advantage and disadvantage of cox 2 inhibitors over non selective ones

A

Less GI effects

More CV risk

40
Q

What effects does ibuprofen have

A

Anti inflammatory
Anti pyretic
Analgesic

41
Q

Examples of NSAIDs that are propionic acid derivatives

A

Naproxen
Fenoprofen
Ketoprofen
Tioprofenic acid

42
Q

Selective cox 2 inhibitor NSAIDs

A 
Parecoxib 
Etoricoxib
Celecoxib 
Diclofenac 
Ibuprofen
43
Q

Counselling point for patients taking the NSAIDs ketoprofen topically

A

Photosensitivity reactions during and 2 weeks after treatment

44
Q

Cautions and contraindications with nsaid use

A 
Elderly 
Asthma 
Coagulation defects- warfarin 
Cv disease 
Gastro problems 
Pregnancy 
Avoid in renal and hepatic impairment
45
Q

What NSAIDs have the highest gastro effects

A

Piroxicam
Ketoprofen
Ketorolac

46
Q

Which NSAIDs have intermediate gastro effects

A

Indometacin
Diclofenac
Naproxen

47
Q

Which nsaid has the lowest gastro risk

A

Ibuprofen

48
Q

What nsaid meds and dose are associated with cv events

A

All nsaid are associated with increased risk of thrombotic events

Ibuprofen 2.4mg daily and diclofenac 150mg daily is associated with increased risk

49
Q

CHM advice for piroxicam

A

Increased risk of GI side effects and serious skin reaction

Not to be used as first line

Limited to RA, Oa

Dose shouldn’t exceed 20mg

Review every 2 weeks when starting

Offer GI protection

Topical use excluded from these restrictions

50
Q

Which nsaid can cause severe cystitis

A

Tiaprofenic acid

51
Q

After how long of taking ibuprofen should you switch to another nsaid if it is not effective

A

3 weeks

52
Q

Max dose of ibuprofen

A

OTC 400mg TDS

Prescription 800mg TDS

53
Q

What’s long term used of ibuprofen associated to

A

Reversibly decreasing female fertility

54
Q

Drugs most NSAIDs interact with

A

Warfarin- increased risk of bleeding

Reduced excretion of methotrexate and lithium

ACEi and diuretic- aki

Potassium sparing diuretic- hyperkalaemia

Quinolones- increased risk of convulsion

Gliclazide (ibuprofen)

55
Q

Which drugs when given with NSAIDs increase GI risk

A

SSRI
Corticosteroids
Aspirin
Clopidogrel

56
Q

Side effects of NSAIDs

A

GI disturbances

Nausea, vomiting, diarrhoea bleeding, ulceration

Hypersensitivity

Headache, dizziness

Blood disorder

Sodium and water retention

57
Q

When can corticosteroid injections be used

A

In highly inflamed joints esp in RA

58
Q

What’s used short term to rapidly improve symptoms of RA

A

Corticosteroids

59
Q

Why’s nsaid contraindicated in severe HF

A

Increased risk of thrombotic event

60
Q

Which NSAIDs have the highest risk in increasing CV events

A

Ibuprofen 2.4g daily
Cox 2 selective
Diclofenac

61
Q

Which NSAIDs have the lowest GI risk

A

Cox 2 selective

62
Q

Uses of methotrexate

A

Rheumatoid arthritis
Cancer
Psoriasis
Crohn’s disease

63
Q

When taking folic acid weekly for methotrexate, after how many missed days should you wait for the next dose

A

> 3

64
Q

Patient counselling for methotrexate

A 
Weekly dosing 
Avoid otc NSAIDs 
Annual flu vaccine 
Methotrexate treatment booklet 
Teratogenic and causes blood dyscrasias
65
Q

Side effects of methotrexate

A

Blood dyscrasias (low wbc, low rbc, low platelet)

Hepatotoxicity

Nephrotoxicity

Pulmonary toxicity

GI toxicity

Teratogenic (contraception even 3 months after for men and women)

Handling (avoid skin contact)

66
Q

What’s gout?

A

A condition that causes sudden severe pain, swelling and redness in the joints caused by the accumulation of uric acid crystals forming in the joints

67
Q

Drugs that cause hyperuricaemia

A

Diuretics
Ciclosporin/ tacrolimus
Cytotoxic
Cancer

68
Q

How long should you not repeat colchicine course

A

Do not repeat course in 3 days

69
Q

Max dose per course of colchicine

A

6mg

70
Q

Allopurinol interactions

A

Reduce dose of mercaptopurine and Azathioprine with allopurinol

(Increased risk of toxicity)

71
Q

When is quinine indicated

A

Sleep is regularly disturbed
Cramps are very painful and frequent
Treatable causes of cramps are excluded
No pharmacological treatments have not worked

72
Q

Serious side effects of quinine

A

QT prolongation
Convulsions
Arrhythmia

73
Q

How often should quinine treatment be assessed

A

Every 3 months

74
Q

Why should you avoid NSAIDs in pregnancy

A

Delays labour
Causes pulmonary hypertension in new born child
Premature closure of foetal ductus arteriosus

75
Q

What nsaid is licensed for migraines

A

Tolfenamic acid

76
Q

Which NSAID causes severe cystitis

A

Tiaprofenamic acid

77
Q

Which nsaid should you caution taking while driving

A

Indometacin

78
Q

Why should you temporarily stop NSAIDs on ‘sick days’ (acute kidney injury)

A

NSAIDs reduce glomerular filtration (eGFR)

NSAID excreted via the kidneys

79
Q

NSAIDs interactions

A

Increased risk of AKI (ACEi, dieuretics, tacrolimus, ciclosporin)

Increased risk of bleeding (warfarin, noac, antiplatelet, heparin, SSRI, steroid)

Reduced renal secretion (methotrexate, lithium)

Increased risk of hyperkalaemia (k sparing)

Increased risk of convulsions (quinolones)

80
Q

From what age can diclofenac be sold otc

A

14 and over

81
Q

When can naproxen be sold otc

A

250mg tabs for period pain- dysmenorrhea
(max 3 tabs daily)

Age 15-50

82
Q

What age can topical NSAIDs be sold to patients

A

Above 12

83
Q

What’s the most effective topical nsaid

A

Ketoprofen

84
Q

What should you avoid doing with sprains, strains and bruising

A

Heat products
Alcohol consumption
Running exercise
Massage

85
Q

From what age can paracetamol and ibuprofen be sold otc

A

Paracetamol 2 month

Ibuprofen 3 months

86
Q

What’s the maximum quantity of paracetamol and aspirin that can be sold otc

A

No more than 100 non-effervescent tablets/ capsules

No legal limit on effervescent products

87
Q

What’s the maximum quantity of co-codamol that can be sold otc

A

32 to over 18s

Pre-reg (27 decks)

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