Chapter 10: Muscoskeletal system COPY 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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What antimalarials can be used for rheumatoid arthritis?

A

Hydroxychloroquine sulfate

Chloroquine- used less frequently

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Do patients with juvenile idiopathic arthritis require DMARD therapy?

A

Usually do not require it however methotrexate can be effective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is leflunomide?

A

DMARD for arthritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Can aspirin be used in gout?

A

No

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

True or false:

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

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

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

A

Allopurinol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is a uricosuric drug?

Give an example

A

One that increases the excretion of uric acid in the urine

Sulfinpyrazone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are the side effects of anticholinesterases?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What kind of drug is neostigmine?

A

Anticholinesterase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is myasthenia gravis?

A

Chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What is used to treat myasthenia gravis?
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
What benzodiazepam is used for muscle spasm?
Diazepam
27
What is baclofen used for?
Spasms Can be used for hiccups in palliative care
28
What can be used for nocturnal leg cramps? Is this recommended for routine treatment?
Quinine salts Not recommended for routine treatment due to potential toxicity Should only be used if cramps cause regular disruption to sleep
29
What is the important safety information regarding the intrathecal use of baclofen?
Test dose is needed Resuscitation equipment must be available for immediate use
30
In rheumatoid arthritis, would paracetamol or NSAIDs be more appropriate?
NSAIDs as they are particularly useful for the treatment of continuous or regular pain associated with inflammation
31
Are selective COX2 inhibitors are associated with less GI or less cardiac side effects compared to non-selective inhibitors?
Less GI side effects They are associated with higher cardiac side effects
32
For acute gout, which NSAID would be less appropriate and why?
Ibuprofen as its anti-inflammatory properties are weaker
33
After ibuprofen, which NSAID is associated with the least amount of side effects?
Naproxen
34
What type of drug is indometacin?
NSAID
35
What are the side effects of indometacin?
GI disturbances Headache Dizziness
36
What NSAIDs are recommended for dental pain?
Ibuprofen | Diclofenac
37
What NSAIDs are associated with the highest risk of cardiovascular events (MI, stroke)?
COX 2 selective inhibitors Diclofenac (150mg daily) Ibuprofen (2.4g daily)
38
What NSAIDs are associated with the lowest risk of cardiovascular events (MI, stroke)?
Naproxen 1g daily | Ibuprofen at a dose of 1.2g daily or less
39
What 3 NSAIDs are associated with the highest risk of GI side effects?
Piroxicam Ketoprofen Ketorolac trometamol
40
What NSAIDs are associated with the lowest risk of GI side effects?
Low dose ibuprofen | COX 2 selective inhibitors
41
What 3 NSAIDs have an intermediate risk of GI side effects?
Indometacin Diclofenac Naproxen
42
Does alcohol increase or decrease the risk of bleed with NSAIDs?
Increase risk
43
How do you manage lower back pain? If this is unsuitable, what should be used?
Oral NSAID Weak opioid and paracetamol Long term opioid therapy should be avoided
44
If a patient presents with low back pain, is it suitable to offer them paracetamol monotherapy?
No- this is ineffective NSAID first line and if not suitable, offer a combination of weak opioid and paracetamol
45
Should SSRIs and TCAs be offered in low back pain?
No | For sciatica patients may need this to manage neuropathic pain however
46
What is the max daily dose of prescribed ibuprofen in adults?
2.4g daily
47
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?
> 100 mg/kg
48
What is the dose of naproxen in acute gout?
Initially 750mg, then 250mg TDS
49
What is the important safety information and guidance on prescribing piroxicam?
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
What is the important safety information associated with tiaprofenic acid?
Reports of severe cystitis Should not be given to patients with urinary tract disorders and stop immediately if urinary symptoms develop
51
What is the maximum number of times in a year a joint should be treated with intra-articular corticosteroid injection?
4 times a year
52
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?
Central rather than peripheral Peipheral cannula should be resited at regular intervals
53
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?
GTN patch - helps with small veins that are prone to collapse
54
True or false: If extravasation injury is suspected, the cannula should be removed immediately
False- not until an attempt has been made to aspirate the area to try and remove the drug
55
If a patient with a cannula in has a suspected extravasation injury, how is this managed?
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
What are the following capsaicin preparations used in: i) 0.025% ii) 0.075% cream iii) 8% patch
i) Hand or knee osteoarthritis ii) Postherpetic neuralgia after lesions have healed, painful diabetic neuropathy iii) Peripheral neuropathic pain in non-diabetic patients.
57
Allopurinol increases the risk of toxicity of which drug? Azathioprine Phenytoin Diltiazem
Azathioprine | Metabolised by xanthine oxidase and allopurinol is an xanthine oxidase inhibitor
58
How do bisphosphonates work?
Inhibit osteoclasts
59
What is the MHRA warning about quinine?
QT prolongation
60
Do NSAIDs cause hypo or hyperkalaemia?
Hyperkalaemia
61
Is paracetamol monotherapy effective in back pain?
No NSAID preferable Then weak opioid and paracetamol combination