Chapter 10: Muscoskeletal system COPY Flashcards
What should be given for newly diagnosed active rheumatoid arthritis?
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
What antimalarials can be used for rheumatoid arthritis?
Hydroxychloroquine sulfate
Chloroquine- used less frequently
Do patients with juvenile idiopathic arthritis require DMARD therapy?
Usually do not require it however methotrexate can be effective
What screening should be done before and then during hydroxychloroquine and chloroquine?
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
What is leflunomide?
DMARD for arthritis
What is a common side effect of penicillamine that needs monitoring?
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
What screening needs to be done before starting infliximab?
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 are acute attacks of gout treated?
If this is not tolerated/not appropriate, what can be used?
High dose NSAIDs e.g. diclofenac, naproxen
Colchicine is an alternative
If resistant to other treatments- oral/parenteral corticosteroids
Can aspirin be used in gout?
No
True or false:
Allopurinol and febuxostat can prolong an acute attack of gout if started in this period
True
When would colchicine be preferred over NSAIDs in an acute flare up of gout?
- If NSAIDs are contraindicated
- In heart failure as unlike NSAIDs, it does not cause fluid retention
- If taking anticoagulants
When would you consider long term control of gout?
- Recurrent acute attacks
- The presence of tophi (swelling where uric crystals have built up)
- Signs of chronic gouty arthritis
How do you manage long term control of gout?
- 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
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?
- 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 long after an acute attack of gout can you long term control (if patient is not already on it)?
1-2 weeks after acute attack has settled
What would be an appropriate choice of long term therapy of gout in renal impairment?
Allopurinol
What is a uricosuric drug?
Give an example
One that increases the excretion of uric acid in the urine
Sulfinpyrazone
How do NSAIDs interact with uricosuric drugs e.g. Sulfinpyrazone?
Aspirin and other salicylates antagonise uricosuric drugs
They do not antagonise allopurinol but are not indicated in gout
What is the maximum dose of colchicine when treating an acute gout phase?
Within how many days should you not repeat the course?
Max 6mg per course
Do not repeat course within 3 days
What can occur in the urine with uricosuric drugs (Sulfinpyrazone)?
What monitoring should be done?
Crystallisation of urate in the urine
Important to ensure adequate urine output for the first few weeks of treatment
What is the MHRA advice of febuxostat?
Serious hypersensitivity reactions including Steven Johnson syndrome
Must not be restarted if history of hypersensitivity
What are the side effects of anticholinesterases?
Increased sweating
Increased salivary and gastric secretions
Increased GI and uterine motility
Bradycardia
What kind of drug is neostigmine?
Anticholinesterase
What is myasthenia gravis?
Chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles
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
What benzodiazepam is used for muscle spasm?
Diazepam
What is baclofen used for?
Spasms
Can be used for hiccups in palliative care
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
What is the important safety information regarding the intrathecal use of baclofen?
Test dose is needed
Resuscitation equipment must be available for immediate use
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
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
For acute gout, which NSAID would be less appropriate and why?
Ibuprofen as its anti-inflammatory properties are weaker
After ibuprofen, which NSAID is associated with the least amount of side effects?
Naproxen
What type of drug is indometacin?
NSAID
What are the side effects of indometacin?
GI disturbances
Headache
Dizziness
What NSAIDs are recommended for dental pain?
Ibuprofen
Diclofenac
What NSAIDs are associated with the highest risk of cardiovascular events (MI, stroke)?
COX 2 selective inhibitors
Diclofenac (150mg daily)
Ibuprofen (2.4g daily)
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
What 3 NSAIDs are associated with the highest risk of GI side effects?
Piroxicam
Ketoprofen
Ketorolac trometamol
What NSAIDs are associated with the lowest risk of GI side effects?
Low dose ibuprofen
COX 2 selective inhibitors
What 3 NSAIDs have an intermediate risk of GI side effects?
Indometacin
Diclofenac
Naproxen
Does alcohol increase or decrease the risk of bleed with NSAIDs?
Increase risk
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
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
Should SSRIs and TCAs be offered in low back pain?
No
For sciatica patients may need this to manage neuropathic pain however
What is the max daily dose of prescribed ibuprofen in adults?
2.4g daily
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
What is the dose of naproxen in acute gout?
Initially 750mg, then 250mg TDS
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
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
What is the maximum number of times in a year a joint should be treated with intra-articular corticosteroid injection?
4 times a year
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
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
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
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
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.
Allopurinol increases the risk of toxicity of which drug?
Azathioprine
Phenytoin
Diltiazem
Azathioprine
Metabolised by xanthine oxidase and allopurinol is an xanthine oxidase inhibitor
How do bisphosphonates work?
Inhibit osteoclasts
What is the MHRA warning about quinine?
QT prolongation
Do NSAIDs cause hypo or hyperkalaemia?
Hyperkalaemia
Is paracetamol monotherapy effective in back pain?
No
NSAID preferable
Then weak opioid and paracetamol combination
