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BNF > Chapter 10: Muscoskeletal system > Flashcards

Chapter 10: Muscoskeletal system Flashcards

1
Q

What should be given for newly diagnosed active rheumatoid arthritis?

A

A combination of DMARDs (including methotrexate and at least one other DMARD) and a short-term corticosteroid

Ideally within 3 months of symptom onset

If combination of DMARDs not possible- monotherapy and increase dose until clinically effective

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2
Q

What antimalarials can be used for rheumatoid arthritis?

A

Hydroxychloroquine sulfate

Chloroquine- used less frequently

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3
Q

Do patients with juvenile idiopathic arthritis require DMARD therapy?

A

Usually do not require it however methotrexate can be effective

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4
Q

What screening should be done before and then during hydroxychloroquine and chloroquine?

A

Before treatment:

  • Renal function
  • LFTs
  • Screen for occular toxicity: Check for visual impairment - any abnormality should be referred to ophthalmologist

During treatment:

  • Refer to ophthalmologist if any visual changes e.g. blurred vision
  • If long term (5 years) treatment is required- arrangement with local ophthalmologist needed
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5
Q

What is leflunomide?

A

DMARD for arthritis

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6
Q

What is a common side effect of penicillamine that needs monitoring?

A

Proteinuria- occurs in 30% of patients

This can be a sign of nephrotoxicity so if any warning symptoms occur e.g. haematuria then stop immediately

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7
Q

What screening needs to be done before starting infliximab?

A

Check for active and latent TB as there is a risk of TB with infliximab

Active TB needs to be treated for at least 2 months before starting infliximab

If previous TB, need to monitor every 3 months

Patients need to report immediately any fever, cough, weight loss

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8
Q

How are acute attacks of gout treated?

If this is not tolerated/not appropriate, what can be used?

A

High dose NSAIDs e.g. diclofenac, naproxen

Colchicine is an alternative

If resistant to other treatments- oral/parenteral corticosteroids

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9
Q

Can aspirin be used in gout?

A

No

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10
Q

True or false:

Allopurinol and febuxostat can prolong an acute attack of gout if started in this period

A

True

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11
Q

When would colchicine be preferred over NSAIDs in an acute flare up of gout?

A
  • If NSAIDs are contraindicated
  • In heart failure as unlike NSAIDs, it does not cause fluid retention
  • If taking anticoagulants
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12
Q

When would you consider long term control of gout?

A
  • Recurrent acute attacks
  • The presence of tophi (swelling where uric crystals have built up)
  • Signs of chronic gouty arthritis
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13
Q

How do you manage long term control of gout?

A
  • Allopurinol or febuxostat (xanthine-oxidase inhibitors to reduce formation of uric acid)
  • Sulfinpyrazone can be an alternative to increase excretion of uric acid in the urine
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14
Q

If a patient is on long term control of gout e.g. allopurinol, but then has an acute attack, how do you manage this?

Do you continue NSAID/colchicine after acute attack?

A
  • Keep allopurinol
  • Treat acute attack with e.g. NSAID/colchicine
  • If patient is not on allopurinol but suitable for prophylaxis, do not start in acute phase. Start 1-2 weeks after attack has settled but continue NSAID or colchicine for at least a month to prevent another acute attack
  • For febuxostat, NSAID/colchicine needs to be continued for at least 6 months after acute attack

Colcichine will be at a lower prophylactic dose of 500mcg BD instead of treatment 500mg BD-QDS

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15
Q

How long after an acute attack of gout can you long term control (if patient is not already on it)?

A

1-2 weeks after acute attack has settled

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16
Q

What would be an appropriate choice of long term therapy of gout in renal impairment?

A

Allopurinol

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17
Q

What is a uricosuric drug?

Give an example

A

One that increases the excretion of uric acid in the urine

Sulfinpyrazone

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18
Q

How do NSAIDs interact with uricosuric drugs e.g. Sulfinpyrazone?

A

Aspirin and other salicylates antagonise uricosuric drugs

They do not antagonise allopurinol but are not indicated in gout

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19
Q

What is the maximum dose of colchicine when treating an acute gout phase?

Within how many days should you not repeat the course?

A

Max 6mg per course

Do not repeat course within 3 days

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20
Q

What can occur in the urine with uricosuric drugs (Sulfinpyrazone)?

What monitoring should be done?

A

Crystallisation of urate in the urine

Important to ensure adequate urine output for the first few weeks of treatment

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21
Q

What is the MHRA advice of febuxostat?

A

Serious hypersensitivity reactions including Steven Johnson syndrome

Must not be restarted if history of hypersensitivity

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22
Q

What are the side effects of anticholinesterases?

A

Increased sweating
Increased salivary and gastric secretions
Increased GI and uterine motility
Bradycardia

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23
Q

What kind of drug is neostigmine?

A

Anticholinesterase

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24
Q

What is myasthenia gravis?

A

Chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles

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25
Q

What is used to treat myasthenia gravis?

A

Immunosuppression e.g. corticosteroids - prednisolone, azathioprine

Steroids are commonly given on alternate days as there is little benefit over daily administration

Anticholinesterase e.g. neostigmine

26
Q

What benzodiazepam is used for muscle spasm?

A

Diazepam

27
Q

What is baclofen used for?

A

Spasms

Can be used for hiccups in palliative care

28
Q

What can be used for nocturnal leg cramps?

Is this recommended for routine treatment?

A

Quinine salts

Not recommended for routine treatment due to potential toxicity
Should only be used if cramps cause regular disruption to sleep

29
Q

What is the important safety information regarding the intrathecal use of baclofen?

A

Test dose is needed

Resuscitation equipment must be available for immediate use

30
Q

In rheumatoid arthritis, would paracetamol or NSAIDs be more appropriate?

A

NSAIDs as they are particularly useful for the treatment of continuous or regular pain associated with inflammation

31
Q

Are selective COX2 inhibitors are associated with less GI or less cardiac side effects compared to non-selective inhibitors?

A

Less GI side effects

They are associated with higher cardiac side effects

32
Q

For acute gout, which NSAID would be less appropriate and why?

A

Ibuprofen as its anti-inflammatory properties are weaker

33
Q

After ibuprofen, which NSAID is associated with the least amount of side effects?

A

Naproxen

34
Q

What type of drug is indometacin?

A

NSAID

35
Q

What are the side effects of indometacin?

A

GI disturbances
Headache
Dizziness

36
Q

What NSAIDs are recommended for dental pain?

A

Ibuprofen

Diclofenac

37
Q

What NSAIDs are associated with the highest risk of cardiovascular events (MI, stroke)?

A

COX 2 selective inhibitors
Diclofenac (150mg daily)
Ibuprofen (2.4g daily)

38
Q

What NSAIDs are associated with the lowest risk of cardiovascular events (MI, stroke)?

A

Naproxen 1g daily

Ibuprofen at a dose of 1.2g daily or less

39
Q

What 3 NSAIDs are associated with the highest risk of GI side effects?

A

Piroxicam
Ketoprofen
Ketorolac trometamol

40
Q

What NSAIDs are associated with the lowest risk of GI side effects?

A

Low dose ibuprofen

COX 2 selective inhibitors

41
Q

What 3 NSAIDs have an intermediate risk of GI side effects?

A

Indometacin
Diclofenac
Naproxen

42
Q

Does alcohol increase or decrease the risk of bleed with NSAIDs?

A

Increase risk

43
Q

How do you manage lower back pain?

If this is unsuitable, what should be used?

A

Oral NSAID

Weak opioid and paracetamol

Long term opioid therapy should be avoided

44
Q

If a patient presents with low back pain, is it suitable to offer them paracetamol monotherapy?

A

No- this is ineffective

NSAID first line and if not suitable, offer a combination of weak opioid and paracetamol

45
Q

Should SSRIs and TCAs be offered in low back pain?

A

No

For sciatica patients may need this to manage neuropathic pain however

46
Q

What is the max daily dose of prescribed ibuprofen in adults?

A

2.4g daily

47
Q

In ibuprofen overdose, how much must the patient have ingested per kg within the preceeding hour in order for them to be suitable for activated charcoal treatment?

A

> 100 mg/kg

48
Q

What is the dose of naproxen in acute gout?

A

Initially 750mg, then 250mg TDS

49
Q

What is the important safety information and guidance on prescribing piroxicam?

A

Restrictions on the use of piroxicam because of the increased risk of gastro-intestinal side effects and serious skin reactions.

  • Should not be used at first line treatment
  • Should not be used for acute inflammatory conditions
  • Initiated by a specialist in inflammatory and rheumatic disease
  • Gastro-protective medicine should be considered
50
Q

What is the important safety information associated with tiaprofenic acid?

A

Reports of severe cystitis

Should not be given to patients with urinary tract disorders and stop immediately if urinary symptoms develop

51
Q

What is the maximum number of times in a year a joint should be treated with intra-articular corticosteroid injection?

A

4 times a year

52
Q

Ideally, drugs likely to cause extravasation injury should be given through what kind of line?

If this is not possible and the patient requires regular treatment e.g. chemo, what is recommended?

A

Central rather than peripheral

Peipheral cannula should be resited at regular intervals

53
Q

What kind of patch can be placed distal to a cannula if a patient is being treated with a drug that could cause extravasation injury?

A

GTN patch - helps with small veins that are prone to collapse

54
Q

True or false:

If extravasation injury is suspected, the cannula should be removed immediately

A

False- not until an attempt has been made to aspirate the area to try and remove the drug

55
Q

If a patient with a cannula in has a suspected extravasation injury, how is this managed?

A

Do not remove the cannula straight away

Try and remove the drug via aspiration through the cannula first

Corticosteroids can be used to treat inflammation e.g. IV/SC hydrocortisone or dexamethasone

Antihistamines and analgesics can be used to relieve symptoms

Call for specialist management after this point

56
Q

What are the following capsaicin preparations used in:

i) 0.025%
ii) 0.075% cream
iii) 8% patch

A

i) Hand or knee osteoarthritis
ii) Postherpetic neuralgia after lesions have healed, painful diabetic neuropathy
iii) Peripheral neuropathic pain in non-diabetic patients.

57
Q

Allopurinol increases the risk of toxicity of which drug?

Azathioprine
Phenytoin
Diltiazem

A

Azathioprine

Metabolised by xanthine oxidase and allopurinol is an xanthine oxidase inhibitor

58
Q

How do bisphosphonates work?

A

Inhibit osteoclasts

59
Q

What is the MHRA warning about quinine?

A

QT prolongation

60
Q

Do NSAIDs cause hypo or hyperkalaemia?

A

Hyperkalaemia

61
Q

Is paracetamol monotherapy effective in back pain?

A

No

NSAID preferable

Then weak opioid and paracetamol combination

BNF (21 decks)

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