Chapter 10- Muscoskeletal System Flashcards
What’s used for pain relief in osteoarthritis and soft tissue disorders
Paracetamol first line
Topical NSAID or capsaicin considered especially in knee or hand osteoarthritis
+- Oral NSAID
Opioid if still not adequate
When should opioid be considered before NSAID in osteoarthritis
If the patient is on low dose aspirin
What’s rheumatoid arthritis
Chronic systemic inflammatory disease that causes persistent inflammation of the synovial joint (typically the small joints of the hands and feet)
What worsens rheumatoid arthritis
At rest or periods of inactivity
Swelling
Tenderness
Heat in the affected joints
What do DMARDs include
Methotrexate Azathioprine Ciclosporin Antimalarials Leflunomide Cytokines modulators
When can you consider doing when starting DMARD for newly diagnosed rheumatoid arthritis
Short term bridging with with a corticosteroid as dmards have a slow onset of action and can take 2-3 months to take effect
Of the DMARDS which are preferred and why
Methotrexate or sulfanazine
They are better tolerated
What should be given in newly diagnosed active rheumatoid arthritis
Combination of DMARDS
(MTX + other)
And short term corticosteroids
How is Gold used as a suppressing drug
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
When should gold treatment be discontinued
Bleeding disorder GI bleeding Ulcers Proteinuria Rash and pruritis
How long would penicillamine treatment take to work and how long should you give it before discontinuing if no improvement
6-12 weeks
1 year
What is used to treat acute gout attacks
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
Why is colchicine preferred over NSAIDs in heart failure
Unlike nsaid it does not induce fluid retention
Given to patients on anticoagulation
How is long term gout managed
Xanthines oxidase inhibitors (allopurinol, febuxostat)
Or uricosuric drug- sulfapyrinazone (increases excretion of Uris acid in the urine
When are management drugs for gout started?
1-2 weeks after the attack has settled
How is hyperuricaemia treated?
Febuxostat
How long is gout management treatment for in recurrent attacks
Indefinitely to prevent further attacks of gout by correcting hyperuricaemia
What can be being for long term management in resistant gout
Allopurinol with sulfinpyrazone
MHRA alert for feboxustat
Rate but serious case of hypersensitivity (stevens Johnson syndrome)
And acute anaphylactic shock
What increases the chance of developing gout
Renal impairment
in patients regularly taking allopurinol and experiance a gout attack should they stop?
No carry on the allopurinol
When should allopurinol be withdrawn
If the patient develops a rash
Apart from gout, when else could allopurinol be taken
Hyperuricaemia associated to cytotoxic drugs
What can be used in myasthenia gravis
First line- Anticholinestrase (eg: neostigmine)
Immunosuppressant therapy
Corticosteroids
Side effects of anticholinestrate used is myasthenia gravis
Muscarinic side effects:
Sweating
Excessive salivation
Bradycardia
When are muscle relaxants used and which ones can be used
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
What’s the purpose of anticholinestrase
To enhance neuromuscular transmission in voluntary and involuntary muscle
Prolong action of Ach
How can the acetylcholinestrase adverse effects be antagonised
Atropine
What can be given for nocturnal leg cramps
Quinine
What severe adverse effects has the use of cytokines modulators been associated with
Infection risk such as:
Tuberculosis
Septicaemia
Hepatitis b reactivation
Why should allopurinol be taken with a full glass of water
To prevent kidney stone and promote uric acid excretion
Excreted via the kidneys
Counselling for allopurinol
May take several months to work
Increase fluid intake to prevent kidney stones
Not for acute attacks (prevent long term)
Counselling points for baclofen used as a muscle relaxer
Dizziness is expected
No alcohol
Do not stop abruptly (slowly reduce dose over 1-2 weeks)
Initiation of gout prevention may precipitate a gout attack, what can you do to prevent this
Give allopurinol as the prevention but give colchicine/ NSAID for 1 month after hyerpuriceamia is corrected
What provides analgesic affect in gout
NSAID
What’s the first choice for pain and stiffness from inflammation
NSAID
How long does it take for NSAIDs to reach its full analgesic and full inflammatory effect
Analgesic reached in 1 week
Inflammatory reached in 3 weeks
Mild- moderate pain relief with first dose
How do NSAIDs work
Reduce production of prostaglandin by inhibiting cyclooxygenase (COX)
What’s an advantage and disadvantage of cox 2 inhibitors over non selective ones
Less GI effects
More CV risk
What effects does ibuprofen have
Anti inflammatory
Anti pyretic
Analgesic
Examples of NSAIDs that are propionic acid derivatives
Naproxen
Fenoprofen
Ketoprofen
Tioprofenic acid
Selective cox 2 inhibitor NSAIDs
Parecoxib Etoricoxib Celecoxib Diclofenac Ibuprofen
Counselling point for patients taking the NSAIDs ketoprofen topically
Photosensitivity reactions during and 2 weeks after treatment
Cautions and contraindications with nsaid use
Elderly Asthma Coagulation defects- warfarin Cv disease Gastro problems Pregnancy Avoid in renal and hepatic impairment
What NSAIDs have the highest gastro effects
Piroxicam
Ketoprofen
Ketorolac
Which NSAIDs have intermediate gastro effects
Indometacin
Diclofenac
Naproxen
Which nsaid has the lowest gastro risk
Ibuprofen
What nsaid meds and dose are associated with cv events
All nsaid are associated with increased risk of thrombotic events
Ibuprofen 2.4mg daily and diclofenac 150mg daily is associated with increased risk
CHM advice for piroxicam
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
Which nsaid can cause severe cystitis
Tiaprofenic acid
After how long of taking ibuprofen should you switch to another nsaid if it is not effective
3 weeks
Max dose of ibuprofen
OTC 400mg TDS
Prescription 800mg TDS
What’s long term used of ibuprofen associated to
Reversibly decreasing female fertility
Drugs most NSAIDs interact with
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)
Which drugs when given with NSAIDs increase GI risk
SSRI
Corticosteroids
Aspirin
Clopidogrel
Side effects of NSAIDs
GI disturbances
Nausea, vomiting, diarrhoea bleeding, ulceration
Hypersensitivity
Headache, dizziness
Blood disorder
Sodium and water retention
When can corticosteroid injections be used
In highly inflamed joints esp in RA
What’s used short term to rapidly improve symptoms of RA
Corticosteroids
Why’s nsaid contraindicated in severe HF
Increased risk of thrombotic event
Which NSAIDs have the highest risk in increasing CV events
Ibuprofen 2.4g daily
Cox 2 selective
Diclofenac
Which NSAIDs have the lowest GI risk
Cox 2 selective
Uses of methotrexate
Rheumatoid arthritis
Cancer
Psoriasis
Crohn’s disease
When taking folic acid weekly for methotrexate, after how many missed days should you wait for the next dose
> 3
Patient counselling for methotrexate
Weekly dosing Avoid otc NSAIDs Annual flu vaccine Methotrexate treatment booklet Teratogenic and causes blood dyscrasias
Side effects of methotrexate
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)
What’s gout?
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
Drugs that cause hyperuricaemia
Diuretics
Ciclosporin/ tacrolimus
Cytotoxic
Cancer
How long should you not repeat colchicine course
Do not repeat course in 3 days
Max dose per course of colchicine
6mg
Allopurinol interactions
Reduce dose of mercaptopurine and Azathioprine with allopurinol
(Increased risk of toxicity)
When is quinine indicated
Sleep is regularly disturbed
Cramps are very painful and frequent
Treatable causes of cramps are excluded
No pharmacological treatments have not worked
Serious side effects of quinine
QT prolongation
Convulsions
Arrhythmia
How often should quinine treatment be assessed
Every 3 months
Why should you avoid NSAIDs in pregnancy
Delays labour
Causes pulmonary hypertension in new born child
Premature closure of foetal ductus arteriosus
What nsaid is licensed for migraines
Tolfenamic acid
Which NSAID causes severe cystitis
Tiaprofenamic acid
Which nsaid should you caution taking while driving
Indometacin
Why should you temporarily stop NSAIDs on ‘sick days’ (acute kidney injury)
NSAIDs reduce glomerular filtration (eGFR)
NSAID excreted via the kidneys
NSAIDs interactions
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)
From what age can diclofenac be sold otc
14 and over
When can naproxen be sold otc
250mg tabs for period pain- dysmenorrhea
(max 3 tabs daily)
Age 15-50
What age can topical NSAIDs be sold to patients
Above 12
What’s the most effective topical nsaid
Ketoprofen
What should you avoid doing with sprains, strains and bruising
Heat products
Alcohol consumption
Running exercise
Massage
From what age can paracetamol and ibuprofen be sold otc
Paracetamol 2 month
Ibuprofen 3 months
What’s the maximum quantity of paracetamol and aspirin that can be sold otc
No more than 100 non-effervescent tablets/ capsules
No legal limit on effervescent products
What’s the maximum quantity of co-codamol that can be sold otc
32 to over 18s
