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2021 Pre-registration > Chapter 10: Musculoskeletal system > Flashcards

Chapter 10: Musculoskeletal system Flashcards

1
Q

What happens in arthritis?

A

The immune system attacks the synovial fluid which results in pain, inflammation and stiffness

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2
Q

Three different types of arthritis?

A

Osteoarthritis
Rheumatoid arthiritis
Spondyloarthritis

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3
Q

What happens in osteoarthritis?

A

cartilage degenerates faster than chondrocytes can repair - essentially wear and tear

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4
Q

Signs and symptoms of osteoarthritis?

A 
Pain
Inflammation
'bony' - bones pop out
Stiffness
Crackling of bones
Tender
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5
Q

Lifestyle measures to help OA?

A

Reduce weight
exercise
reduce strain on joints
suitable footwear

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6
Q

OA commonly affects…

A

More in women than men

- affects knees, hands, hips

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7
Q

Treatment for OA?

A

1) paracetamol
2) NSAIDS / capsaicin 0.0025% cream QDS
3) Opioids

Note: if patient is on aspirin 75mg, give opioids before NSAIDs

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8
Q

What is not recommended for OA treatment?

A

Rubefacients and glucosamine - only for symptomatic relief

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9
Q

Which injections can be given intra-articularly in OA?

A
  • corticosteroid injections: temp benefit especially if there is also tissue inflammation
  • sodium hyaluranote injections in synovial fluid, reduces pain in 1-6mths but increases risk of knee inflammation
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10
Q

Methotrexate interactions?

A

1) Antivirals e.g. aciclovir/alcohol/antifungals/ceftriaxone/carbamazepine: hepatoxicity
2) Aciclovir/trimethoprim/ciclosporin/NSAIDs - nephrotoxic
3) penicillins/quinolones - increased toxicity
4) Bleomycin - myelosuppression and thromboembolism risk
5) Aminophylline: decreased clearance and increased levels
6) live vaccine e.g. yellow fever - life threatening infections

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11
Q

Compare OA and RA

A

OA is generally not inflammatory. OA is not relieved by exercise like RA - symptoms could worsen

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12
Q

What is RA?

A

Chronic inflammatory disease that causes persistent inflammation (mainly of small joints of hands/feet)

  • immune system attacks synovial fluid
  • pain and prolonged stiffness that is even worse at rest
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13
Q

Why is it critical to identify and treat RA early?

A

It can progress to other organs such as lungs, heart and eyes

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14
Q

Symptoms of RA?

A

Pain (particularly at rest often relieved with exercise), stiffness, inflammation
Fatigue
Muscle ache
weight loss

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15
Q

Pain from an inflammatory condition is _____

A

Worse at rest and better with exercise. Pain from a mechanical problem e.g. OA - is better with rest and worse with activity

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16
Q

Refer all patients suspected with ________ due to risks of RA progession

A

persistent inflammation

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17
Q

Diagnosis of RA includes:

A
  • observation of inflammation (particularly hands)
  • inflammatory markers e.g. CRP and ESR
  • duration around 6 weeks of persistent inflammation
  • Rheumatoid factor/anti-CCP
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18
Q

Treatment for RA (based on NICE)?

A

1) DMARDS: methotrexate, leflunomaide, sulfasalazine (take 2-3mths to work) so bridge with steroids
2) Mild DMARD: hydroxychloroquine - visual acuity and nightmares
3) Monoclonal antibodies/TNF-a inhibitors: adalimumab, etanercept, tocilizumab, infliximab
4) surgery
5) pain-relief: NSAIDS/cox-2 inhibitors but GI adv effects so co-prescribe PPI if suitable

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19
Q

What side effects are particularly prominent in those with monoclonal antibodies?

A

Immunosuppression - increased risk of infections

Can reactivate dormant infections such as TB/Hep B

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20
Q

Caution with hydroxochloroquine?

A

Monitor retnipathy - if long term tx do a baseline eye test and another within 6-12mths

> 5yrs tx: annual eye test
<5yrs + risk factors e.g. tamoxifen, impaired renal func, dose >5mg/kg/day: do annual eye test

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21
Q

Hydroxychloroquine and overdose.

A

Very hard to treat. Presents with arrhythmias and convulsions

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22
Q

What can be used for juvenile idiopathic arthritis?

A

methotrexate

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23
Q

MHRA warning for tocilizumab used in RA?

A

Serious liver injury, may require liver transplantation

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24
Q

Notable side-effects of methotrexate?

A
  • Mouth ulcers and mucositis
  • Liver toxicity
  • Pulmonary fibrosis
  • Bone marrow suppression and leukopenia (low white blood cells)
  • It is teratogenic (harmful to pregnancy) and needs to be avoided prior to conception in mothers and fathers
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25
Notable side-effects of leflunomide?
Mouth ulcers and mucositis Increased blood pressure Rashes Peripheral neuropathy Liver toxicity Bone marrow suppression and leukopenia (low white blood cells) It is teratogenic (harmful to pregnancy) and needs to be avoided prior to conception in mothers and fathers
26
Notable side-effects of sulfasalazine?
Temporary male infertility (reduced sperm count) | Bone marrow suppression
27
Notable side-effects of hydroxychloroquine?
Nightmares Reduced visual acuity (macular toxicity) Liver toxicity Skin pigmentation
28
Notable side-effects of Anti-TNF drugs?
vulnerability to severe infections and sepsis | Reactivation of TB and hepatitis B
29
Notable side-effects of rituximab?
``` Vulnerability to severe infections and sepsis Night sweats Thrombocytopenia (low platelets) Peripheral neuropathy Liver and lung toxicity ```
30
Key SE of RA treatmenet?
Methotrexate: pulmonary fibrosis Leflunomide: Hypertension and peripheral neuropathy Sulfasalazine: Male infertility (reduces sperm count) Hydroxychloroquine: Nightmares and reduced visual acuity Anti-TNF medications: Reactivation of TB or hepatitis B Rituximab: Night sweats and thrombocytopenia
31
What is the antidote for methotrexate?
Folinic acid
32
Talk about methotrexate dosing.
Once weekly (same day every week) Take folic acid 24-48hrs after day of methotrexateto reduce side-effects and toxicity
33
Woman of child-bearing age is given methotrexate for RA, what do you advise?
Effective contraception during and 6months after (even if a man) - is teratogenic
34
What OTC remedies should be avoided with methotrexate?
Nsaids/aspirin: risk of blood dysrasias
35
What medication can increase the risk of MTX toxicity?
Theo/Amino-phylline, quinolones, penicillin
36
Which vaccine should be avoided with MTX?
Live vaccines e.g. yellow fever as increases risk of serious infections
37
Which group of NSAIDS pose the lowest risk of GI SE/Toxicity?
Coxibs
38
How long does it take NSAIDS to work?
pain relief: 1st dose analgesia: 1 week anti-inflammatory: 3 weeks ^if inapp response, choose another NSAID
39
What NSAIDS have the highest risk of GI toxicity?
ketoprofen / piroxicam medium: diclofenac and naproxen
40
What NSAIDS have the lowest risk of GI toxicity?
ibuprofen
41
Above what daily dose of NSAIDS is there an increased risk of CVS effects e.g. risk of MI/stroke/HF
>2.4g
42
Side-effects of NSAIDs?
bronchospasm - avoid is asthma hypersensitivity - NSAIDS/aspirin previous allergies photosensitivity - use SPF esp with ketoprofen nephrotoxic: caution in renal imp and avoid during sick days fluid and sodium retention so avoid in heart failure
43
How would you prevent GI SE of NSAIDS?
Add PPI Take with food not for anyone who is actively bleeding
44
Can NSAIDS be used in pregnancy?
No. Especially not in 3rd trimester due to induction of labour and pulmonary hypertension
45
Interactions with NSAIDs?
1) Aki: ace/ard/tacrolimus/ciclosporin/diuretics 2) bleeding - warfarin, DOAC, heparin 3) reduced renal function 4) hyperkalaemia: ace/arb/ald antag/potassium sparing 5) convulsions: quinolones
46
First line treatment for acute attacks of gout?
1) NSAIDS - diclofenac, eterocoxib, indometacin, ketoprofen, naproxen
47
Alternative treatment for acute gout attacks if NSAIDs are not tolerated?
Alt: Colchicine (max 12mg per course - due to risk of toxicity with higher doses)
48
Benefits of using colchicine?
Can be used in heart failure (as doesnt cause fluid retention) and in those using anti-coagulants
49
In those who cannot tolerate NSAIDS and colchicine for gout, what is an option?
Oral or parenteral corticosteroids
50
Long-term treatment for gout should be initiated after ______
1-2 weeks of the gout as it can trigger an attack
51
Long-term gout treatment is controlled by ______
NSAIDS (if tolerated) and colchicine for a minimum of one month
52
How would prophylactic treatment for gout be managed if a patient has an attack whilst on preventative treatment?
Continue with therapy and treat attack separately
53
Is allopurinol suitable in those with renal impairment?
Yes
54
Particular SE of allopurinol?
Rash
55
Can aspirin be used for gout?
No
56
What medication apart from colchicine can be used for treatment of gout?
Febuxostat | Rasburicase - mainly in haem/cancer pts
57
With enzyme ______ the dose of colchicine should be reduced by _________
inhibitors (sickfaces.com) | Reduce dose by 50-75% (75% if potent)
58
Which drug requires a dose reduction to 1/4 with allopurinol?
Azathioprine
59
Max dose of allopurinol daily?
100mg
60
CALS with allopurinol?
Do not stop taking unless doctor tells you to stop Take with food/after meal Take with a full glass of water
61
Ensure adequate _____ whilst on gout medication
adequate fluid intake
62
Febuxostat MHRA warnings?
- not for those with a hx of cardiac disease as increased risk of CVS death - serious hypersensitivity reactions - SJS
63
After starting Febuxostat how long should prophylactic NSAIDS or colchine be continued for and why?
6 months to prevent gout attacks
64
Indication for rasburicase?
prophylaxis and treatment for hyperuricaemia before and after starting chemotherapy - v.expensive 200-300 pounds
65
Rasburicase contra-indication?
G6PD deficiency
66
Rasburicase SE?
Monitor for hypersensitivity
67
Rasburicase storage requirement and strength?
Keep in fridge 1.5mg/5ml Dose 200mg/kg upto 7 days and then go back down to allopurinol or febuxostat
68
What is myasthenia gravis?
Muscle weakness that occurs due to ache receptor blockade by ach antibodies at neuromuscular junction (autoimmune) and linked to thymoma (thymus cancer) Increased activity = less effective stimulation
69
Symptoms of myasthenia gravis?
diplopia droopy eyes unilateral arm weakness tests: ct/mri of thymus gland and ach-receptor antibodies
70
1st line for myasthenia gravis?
anticholinesterase inhibitors e.g. neostigmine (effect for 4hrs max 180mg daily) and pyridostigmine (slow but longer MOA) - STOPP criteria (increase ach levels by inhibiting the enzyme that breaks down ach - allowing for more receptor occupancy)
71
2nd line for m.gravis?
Corticosteroids (suppress antibody production) and if want to wean then use immunosuppressants like azathioprine
72
Which surgery can relieve M.gravis even if there is no tumour?
Thymectomy - linked to this gland
73
If someone with myasthenia gravis had a respiratory infection, what would you be concerned about?
Can trigger a myasthenic crisis where lung muscles are unable to contract effectively so pt may need o2 and/or bipap
74
AntiCHOLINESTERASE, muscuranic side-effects?
Dribbling Increases GI motility - diarrhoea bradycardia - KEY esp if HR <60bpm increased sweating
75
Baclofen can be used in muscle spasms. What are the major side-effects?
Sedation Muscular hypotonia - as depresses CNS Hence dantrolene is drug of choice as acts directly on skeletal muscle
76
Signs of overdose for acetylcholinesterase? Why is this a concern
``` Ex. bradycardia Ex. drooling Diarrhoea Heart block arrhythmias hypotension agitation ex. dreaming weakness ( and can lead to paralysis ) ```
77
What is used for nocturnal leg cramps?
Quinine but not routinely used unless it causes disruption to sleep as toxic - helps around 25% patients
78
How often should quinine treatment be reviewed to ensure it is still suitable and prevent toxicity?
every 3 months
79
How long could quinine take to work?
4 weeks
80
What is sciatica?
neuropathic pain due to prolonged compression of lumbosacral nerve - can undergo spinal decompression
81
Selective inhibition of _______ = less GI SE
COX 2
82
Which NSAID can be given OD?
piroxicam as long MOA
83
Which NSAIDS increase the risk of MI/STROKE?
Cox-2 selectives e.g. celecoxib but reduced GI SE
84
NSAID can cause deterioration of renal function particularly in those with an egfr>...
EGFR<50ml/min
85
Which non-selective NSAID has the lowest risk of GI SE?
ibuprofen (not high dose)
86
Ways to reduce symptoms like dyspepsia in those taking NSAIDS?
With milk/food | Enteric-coated formulation
87
Which lifestyle habit interacts with NSAIDS and what is the consequence?
Alcohol (not moderate) but those that heavy drink/alcohol dependance = increased risk of GI haemmorhage and AKI
88
With which drug should the dose of celecoxib be halved?
Fluconazole
89
Do NSAIDS affect fertility?
long term use = reduced fertility (stops when treatment stops)
90
Counselling points for topical NSAIDS?
photosensitivty wash hands after use excess usage can cause systemic SE
91
NSAID Poisoning treatment?
Activated charcoal
92
Signs of NSAID toxicity?
tinnitus epigastric pain n/v
93
Ibuprofen suspension comes in what strength?
100mg/5ml
94
Ibuprofen child dosing:
1-2months: 5mg/kg TDS/QDS 3-5months: 2.5ml TDS 6-11months: 2.5ml TDS/QDS 1yrs to 3yrs: 5ml TDS 4yrs to 6yrs: 7.5ml TDS 7yrs to 9yrs: 10ml TDS 10-11yrs: 10-15ml TDS 12+: 15-20ml TDS/QDS
95
Mefenamic acid in overdose can cause _____
convulsions
96
Intra-articular steroid injections can be given for RA. What is the maximum number of times this can be given in a year?
4 times
97
Significant SE of hydrocortisone intra articular?
Myocardial rupture (if used after recent mi)

2021 Pre-registration (15 decks)

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