Chapter 10: Muscoskeletal system COPY

Question 1

What should be given for newly diagnosed active rheumatoid arthritis?

Answer 1

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

Question 2

What antimalarials can be used for rheumatoid arthritis?

Answer 2

Hydroxychloroquine sulfate

Chloroquine- used less frequently

Question 3

Do patients with juvenile idiopathic arthritis require DMARD therapy?

Answer 3

Usually do not require it however methotrexate can be effective

Question 4

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

Answer 4

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

Question 5

What is leflunomide?

Answer 5

DMARD for arthritis

Question 6

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

Answer 6

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

Question 7

What screening needs to be done before starting infliximab?

Answer 7

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

Question 8

How are acute attacks of gout treated?

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

Answer 8

High dose NSAIDs e.g. diclofenac, naproxen

Colchicine is an alternative

If resistant to other treatments- oral/parenteral corticosteroids

Question 9

Can aspirin be used in gout?

Answer 9

No

Question 10

True or false:

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

Answer 10

True

Question 11

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

Answer 11

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

Question 12

When would you consider long term control of gout?

Answer 12

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

Question 13

How do you manage long term control of gout?

Answer 13

• 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

Question 14

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?

Answer 14

• 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

Question 15

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

Answer 15

1-2 weeks after acute attack has settled

Question 16

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

Answer 16

Allopurinol

Question 17

What is a uricosuric drug?

Give an example

Answer 17

One that increases the excretion of uric acid in the urine

Sulfinpyrazone

Question 18

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

Answer 18

Aspirin and other salicylates antagonise uricosuric drugs

They do not antagonise allopurinol but are not indicated in gout

Question 19

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

Within how many days should you not repeat the course?

Answer 19

Max 6mg per course

Do not repeat course within 3 days

Question 20

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

What monitoring should be done?

Answer 20

Crystallisation of urate in the urine

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

Question 21

What is the MHRA advice of febuxostat?

Answer 21

Serious hypersensitivity reactions including Steven Johnson syndrome

Must not be restarted if history of hypersensitivity

Question 22

What are the side effects of anticholinesterases?

Answer 22

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

Question 23

What kind of drug is neostigmine?

Answer 23

Anticholinesterase

Question 24

What is myasthenia gravis?

Answer 24

Chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles

Question 25

What is used to treat myasthenia gravis?

Answer 25

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

Question 26

What benzodiazepam is used for muscle spasm?

Answer 26

Diazepam

Question 27

What is baclofen used for?

Answer 27

Spasms Can be used for hiccups in palliative care

Question 28

What can be used for nocturnal leg cramps? Is this recommended for routine treatment?

Answer 28

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

Question 29

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

Answer 29

Test dose is needed Resuscitation equipment must be available for immediate use

Question 30

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

Answer 30

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

Question 31

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

Answer 31

Less GI side effects They are associated with higher cardiac side effects

Question 32

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

Answer 32

Ibuprofen as its anti-inflammatory properties are weaker

Question 33

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

Answer 33

Naproxen

Question 34

What type of drug is indometacin?

Answer 34

NSAID

Question 35

What are the side effects of indometacin?

Answer 35

GI disturbances Headache Dizziness

Question 36

What NSAIDs are recommended for dental pain?

Answer 36

Ibuprofen | Diclofenac

Question 37

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

Answer 37

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

Question 38

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

Answer 38

Naproxen 1g daily | Ibuprofen at a dose of 1.2g daily or less

Question 39

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

Answer 39

Piroxicam Ketoprofen Ketorolac trometamol

Question 40

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

Answer 40

Low dose ibuprofen | COX 2 selective inhibitors

Question 41

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

Answer 41

Indometacin Diclofenac Naproxen

Question 42

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

Answer 42

Increase risk

Question 43

How do you manage lower back pain? If this is unsuitable, what should be used?

Answer 43

Oral NSAID Weak opioid and paracetamol Long term opioid therapy should be avoided

Question 44

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

Answer 44

No- this is ineffective NSAID first line and if not suitable, offer a combination of weak opioid and paracetamol

Question 45

Should SSRIs and TCAs be offered in low back pain?

Answer 45

No | For sciatica patients may need this to manage neuropathic pain however

Question 46

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

Answer 46

2.4g daily

Question 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?

Answer 47

> 100 mg/kg

Question 48

What is the dose of naproxen in acute gout?

Answer 48

Initially 750mg, then 250mg TDS

Question 49

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

Answer 49

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

Question 50

What is the important safety information associated with tiaprofenic acid?

Answer 50

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

Question 51

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

Answer 51

4 times a year

Question 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?

Answer 52

Central rather than peripheral Peipheral cannula should be resited at regular intervals

Question 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?

Answer 53

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

Question 54

True or false: If extravasation injury is suspected, the cannula should be removed immediately

Answer 54

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

Question 55

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

Answer 55

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

Question 56

What are the following capsaicin preparations used in: i) 0.025% ii) 0.075% cream iii) 8% patch

Answer 56

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

Question 57

Allopurinol increases the risk of toxicity of which drug? Azathioprine Phenytoin Diltiazem

Answer 57

Azathioprine | Metabolised by xanthine oxidase and allopurinol is an xanthine oxidase inhibitor

Question 58

How do bisphosphonates work?

Answer 58

Inhibit osteoclasts

Question 59

What is the MHRA warning about quinine?

Answer 59

QT prolongation

Question 60

Do NSAIDs cause hypo or hyperkalaemia?

Answer 60

Hyperkalaemia

Question 61

Is paracetamol monotherapy effective in back pain?

Answer 61

No NSAID preferable Then weak opioid and paracetamol combination