Chapter 10: Musculoskeletal system Flashcards
Azathrioprine
Ciclosporin
Cyclophosphamide
Leflunomide
Penicillamine
Methotrexate
Gold
Are all seen in which condition?
These are the DMARDs used in Rhumatoid arthritis
Hydroxychloroquine is indicated for active rhumatoid arthritis. What is a big warning with this drug?
Screening for ocular toxicity is required- monitor visual symptoms during treatment
What drugs are used in the treatment of Gout?
Colchicine
Allopurinol
sulfinpyrazone
febuxostat
What severe hypersensitivity reaction has been associated with Febuxostat use?
Steven Johnsons syndrome
Stop immediately if steven johnsons ulcer like rash occurs
Why must we avoid abrupt withdrawal with Baclofen?
baclofen relieves muscles spasms and helps manage conditions cerebral palsy, meningitis, motor neurone disease and multiple sclerosis
Risk of hyperactive state- hyperthermia, psychiatric reactions, convulsion. Dose should be discontinued gradually over 1-2 weeks
What should patients on Baclofen be advised with regards to driving?
Baclofen may cause drowsiness
Other
May cause hallucinations
Constipation /diarrhoea
Dry mouth
Hyperhidrosis
What are Aceclofenac, Acemetacin, Celecoxib, Etodolac,
Felbinac
Indometacin
Mefenamic acid All examples of?
NSAIDs
Why have restrictions on the use of Piroxicam been put forward?
Increased risk of Gastro-intestinal side effects and of serious skin reactions. Should not be used first line
Should be initiated by a specialist
Should only be used for rheumatoid arthritis not for pain anymore
(this guidance does not effect topical preps only oral)
What is the big safety warning with TIAPROFENIC ACID (an NSAID)?
It can cause SEVERE CYSTITIS
DO NOT give to patients with UTI disorders!
Stop if symptoms develop- increased frequency, nocturia, urgency, pain on urination, blood in urine.
Etanercept
adalimumab
Liximab
Certolizumab
Golimumab
Infliximab
What are all these used in?
Rhumatoid arthritis
Chrons
Ulcerative colitis
‘Cytokine Modulators’
What should patients taking Cytokine Modulators be advised to look out for?
Etanercept
adalimumab
Liximab
Certolizumab
Golimumab
Infliximab
TUBERCULOSIS:
(they’re immunosuppressant so infection with TB more likely)
Signs: persistent cough, Hemoptysis (coughing blood), weight loss
BLOOD DISORDERS: agranulocytosis: fever, sore throat, bruising, bleeding
Which NSAID carries the lowest risk of CV effects?
Naproxen
Which NSAID carries the lowest risk of Gastro-intestinal side effects?
Ibuprofen
Acute attacks of gout are usually managed how?
Acute attacks of gout are usually treated with high doses of NSAIDs such as diclofenac sodium, diclofenac potassium, etoricoxib, indometacin, ketoprofen, naproxen or sulindac.
Colchicine is an alternative in patients unable to take NSAIDs such as history of CVD issues, Active gastro-intestinal bleeding
What is an alternative to high dose NSAIDs for the treatment of acute attacks of gout?
Colchicine is an alternative in patients in whom NSAIDs are contra-indicated. Aspirin is not indicated in gout.
What medication should not be used to treat acute attacks of gout due to a risk of prolonging the attack indefinitely? (3)
Allopurinol, febuxostat, and uricosurics are not effective in treating an acute attack and may prolong it indefinitely if started during the acute episode.
The use of colchicine to manage acute gout is limited by what?
The use of colchicine is limited by the development of toxicity at higher doses, but it is of value in patients with heart failure since, unlike NSAIDs, it does not induce fluid retention; moreover, it can be given to patients receiving anticoagulants.
The use of colchicine is limited by the development of toxicity at higher doses, but it is of value in patients with heart failure for what reason?
The use of colchicine is limited by the development of toxicity at higher doses, but it is of value in patients with heart failure since, unlike NSAIDs, it does not induce fluid retention; moreover, it can be given to patients receiving anticoagulants.
What treatment options are there for acute gout in those who cannot tolerate NSAIDs and in whom the use of colchicine has been ineffective?
Oral or parenteral corticosteroids are an effective alternative in those who cannot tolerate NSAIDs or who are resistant to other treatments. Intra-articular injection of a corticosteroid can be used in acute monoarticular gout [unlicensed indication]. A corticosteroid by intramuscular injection can be effective in podagra.Canakinumab, a recombinant monoclonal antibody, can be used for the symptomatic treatment of frequent gouty arthritis attacks (at least 3 in the previous 12 months). It is licensed for use in patients whose condition has not responded adequately to treatment with NSAIDs or colchicine, or who are intolerant of them.
What is Canakinumab?
Canakinumab, a recombinant monoclonal antibody, can be used for the symptomatic treatment of frequent gouty arthritis attacks (at least 3 in the previous 12 months). It is licensed for use in patients whose condition has not responded adequately to treatment with NSAIDs or colchicine, or who are intolerant of them.
Canakinumab is a recombinant monoclonal antibody which can be used for the symptomatic treatment of frequent gouty arthritis attacks, which is defined as how many in the previous 12 months?
Canakinumab, a recombinant monoclonal antibody, can be used for the symptomatic treatment of frequent gouty arthritis attacks (at least 3 in the previous 12 months). It is licensed for use in patients whose condition has not responded adequately to treatment with NSAIDs or colchicine, or who are intolerant of them.
For long-term control of gout the drugs allopurinol, febuxostat and sulfinpyrazone may be used. How do they work?
Both allopurinol and febuxostat reduce the formation of uric acid from purines as they are xanthine-oxidase inhibitors. Sulfinpyrazone is an uricosuric drug which may be used to increase the excretion of uric acid in the urine.
Allopurinol, febuxostat and sulfinpyrazone should never be started during an acute attack of gout, they are usually started how long after an attack has settled?
1-2 weeks.
The initiation of long-term treatment for gout may precipitate an acute attack. How is this managed?
The initiation of treatment may precipitate an acute attack, and therefore an anti-inflammatory analgesic or colchicine should be used as a prophylactic and continued for at least one month after the hyperuricaemia has been corrected. However, if an acute attack develops during treatment, then the treatment should continue at the same dosage and the acute attack treated in its own right.
Allopurinol is widely used and is especially useful in patients with renal impairment or urate stones when what drugs cannot be used?
Uricosuric drugs cannot be used.
What side effect can allopurinol cause?
Rashes
Stevens-Johnson syndrome is a rare side effect of allopurinol. It causes flu-like symptoms, followed by a red or purple rash that spreads and forms blisters. The affected skin eventually dies and peels off.
It’s more likely to happen in the first 8 weeks of taking allopurinol, or when the dose is increased too quickly. It can also happen if allopurinol is stopped suddenly for a few days and then restarted at the same dose as before. It’s better to reduce the dose and then increase it slowly.
It’s also best to not start taking allopurinol within 2 weeks of a viral infection, vaccination, or rash caused by something else.
Febuxostat is licensed for the treatment of chronic hyperuricaemia where what has already occured?
Where urate deposition has already occured. It is not indicated for patients in whom the rate of urate formation is greatly increases such as in malignant disease or in Lesch-Nyhan syndrome.
Can allopurinol and sulfinpyrazone be used in conjunction?
Yes:Sulfinpyrazone can be used instead of allopurinol or in conjunction with it in cases that are resistant to treatment.
What is a Specials uricosuric drug that can be used in patients with mild renal impairment?
Benzbromarone (available from ‘special-order’ manufacturers or specialist importing companies) is a uricosuric drug that can be used in patients with mild renal impairment.
Why should increased fluid intake be encouraged in patients receiving treatment for gout?
Crystallisation of urate in the urine can occur with the uricosuric drugs and it is important to ensure an adequate urine output especially in the first few weeks of treatment. As an additional precaution the urine may be rendered alkaline.
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 (DMARD) 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
Counselling on the symptoms of blood disorders is advised. Warn patient and carers to tell doctor immediately if sore throat, fever, infection, non-specific illness, unexplained bleeding and bruising, purpura, mouth ulcers, or rashes develop.
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
Acute gout
By mouth
500 micrograms 2–4 times a day until symptoms relieved, maximum 6 mg 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 urineImportant 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 or 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 (ketorolac, celecoxib) 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 ❤️
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 cystitisShould 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 awayTry and remove the drug via aspiration through the cannula firstCorticosteroids can be used to treat inflammation e.g. IV/SC hydrocortisone or dexamethasoneAntihistamines and analgesics can be used to relieve symptomsCall for specialist management after this point
What are the following capsaicin preparations used in:i) 0.025% ii) 0.075% creamiii) 8% patch
i) Hand or knee osteoarthritisii) Postherpetic neuralgia after lesions have healed, painful diabetic neuropathyiii) Peripheral neuropathic pain in non-diabetic patients.
Allopurinol increases the risk of toxicity of which drug?AzathioprinePhenytoinDiltiazem
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 preferableThen weak opioid and paracetamol combination
