Chapter 10: Musculoskeletal system Flashcards
AzathrioprineCiclosporinCyclophosphamideLeflunomidePenicillamineMethotrexateGoldAre 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?
ColchicineAllopurinolsulfinpyrazonefebuxostat
What severe hypersensitivity reaction has been associated with Febuxostat use?
Steven Johnsons syndromeStop immediately if steven johnsons ulcer like rash occurs
Why must we avoid abrupt withdrawal with Baclofen?
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
What are Aceclofenac, Acemetacin, Celecoxib, Etodolac,FelbinacIndometacinMefenamic 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 lineShould 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 CYSTITISDO NOT give to patients with UTI disorders!Stop if symptoms develop- increased frequency, nocturia, urgency, pain on urination, blood in urine.
EtanerceptadalimumabLiximabCertolizumabGolimumab InfliximabWhat are all these used in?
Rhumatoid arthritisChronsUlcerative colitis ‘Cytokine Modulators’
What should patients taking Cytokine Modulators be advised to look out for?EtanerceptadalimumabLiximabCertolizumabGolimumab Infliximab
TUBERCULOSIS:(they’re immunosuppressant so infection with TB more likely)Signs: persistent cough, Hemoptysis (coughing blood), weight lossBLOOD 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.
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 3 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
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 corticosteroidIdeally 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 sulfateChloroquine- 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 ophthalmologistDuring 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 patientsThis can be a sign of nephrotoxicity so if any warning symptoms occur e.g. haematuria then stop immediately