Clinical Pharmacy II Flashcards
Muscoskeletal conditions
What are the risk factors of rheumatoid arthritis?
Gender (female higher risk)
Age (40-60) - can occur in children
Genetics - associated with HLA-DR4 allele
Cigarette smoking
How does rheumatoid arthritis arise?
Increase in number of inflammatory cells
Release cytokines -> proteolytic enzymes -> destruction of bone and cartilage
Clinical features of rheumatoid arthritis (symptoms and signs)
Joint pain and swelling - last more than 6 weeks -> symmetrical
Stiffness in the morning - more than 30 minutes
Fever
Weight loss
Fatigue and malaise
Depression
Presence of rheumatoid nodules
Raised CRP and ESR
Raised rheumatoid factor - not all patients
Deformity of bones
Why does the ESR reading increase in rheumatoid arthritis?
Inflammation -> produced proteins -> affect the repellant surface of RBC
RBC can stack easier -> faster rate of settlement -> higher ESR value
How is rheumatoid arthritis diagnosed?
No specific test
Suspected -> refer
Use some tests to speed up the diagnostic processes -> act like baseline measurement before treatment.
What are the tests that can be used as baseline measurement for the diagnosis and treatment monitoring of rheumatoid arthritis?
Full blood count - signs of anaemia
CRP and ESR level - inflammation
Urea and electrolytes - kidney function - risk from treatments
Liver function test - active RA can cause raised gamma-glutamic transferase and alkaline phosphatase
Rheumatoid factor level
Antinuclar Ig and anti-CCP Ig present - antibodies linked with RA
Imaging through MRI, ultrasoun - radiography of hand, feet and chest
What is anti-CCP IG and antinuclear Ig? How are they related to RA?
Antinuclear Ig - linked with connective tissue diseases
Anti-CCP Ig = anti-cyclic citrullinated peptide Ig - chronic inflammation produced Ig
What type of anaemia in rheumatoid disease?
Secondary anaemia
Number of immature RBC is normal or low
Morpholgy of bone marrow normal
What are the differences between anaemia of chronic disease and iron deficiency anaemia (IDA), in terms of blood measurement?
Both have low serum
Anaemia of chronic disease has normal or high serum ferritin (low in IDA)
Normal or low transferrin level (high in IDA)
Low total iron binding capcity (high in IDA)
Explain the trend of ferritin level, serum level and transferrin level in chronic disease anaemia.
Due to body response to inflammation
Increase IL-4 -> increase Hepcidin production from liver
Hepcidin - reduce Fe absorbed from gut -> low Fe serum
Body response -> reduce iron-transferring protein (transferrin) and increase iron-stored protein (ferritin)
What are the three management approach for RA?
Non-pharmacological treatment
Drug treatment
Surgical treatment
Can be combine or mono
What is the target of treating active RA in adults?
Treat-to-target therapy
Achieve target remission OR low disease activity if remission is impossible
Name the classes of drugs that need to be used for RA management
cDMARDs (conventional disease-modifying anti-rheumatic drugs)
biological DMARDs
NSAIDs, PPIs, glucocorticoids - symptom control
Describe the clinical management of active RA (first-line etc).
First-line: Monotherapy cDMARDs - ASAP, within 3 months of the onset of persistent symptoms - if toleratance, dose increase
Second-line: Combination of cDMARD - only start when dose escalation not work
Third-line: Biological DMARDs (with or without methotrexate) - only use if inadequate response to cDMARDs combo or if classed severe - withdraw if moderate resp not achieve within 6 months
Fourth-line: Rituximab + Methotrexate
Fifth-line: Sarilumab/Tocilizumab + Methotrexate
What is the consideration when switching cDMARDs?
Bridging therapy with glucocorticosteroids (short-term)
How is RA classed severe?
Das28 score above 5.1
What criteria is used to assess if the response to treatment is adequate?
EULAR criteria
Name cDMARDs used to manage RA in first and second-line
Methotrexate and sulfasalazine (most tolerated)
Gold (auranofin, sodium aurothionate)
Penicillamine
Hydroxychloroquine
Ciclosproins
Azathioprine
Monitoring requirements for cDMARDs
All require: FBCs, eGFRs, LFTs - some drugs require more:
Azathioprine - TPMT assay - level of metabolic enzyme
Ciclosporin - fasting lipids and BP - risk of hyperlipidaemia and HTN
Hydroxychloroquine - visual acuity - side effect of ocular toxicity
Methotrexate - chest X-ray - risk of pneumonitis
Why is FBC required to be monitored during RA treatment?
Most of the drugs cause myelosuppression - reduced blood cells production
Dose of methotrexate for RA.
7.5 - 22.5 mg once weekly
Dose of sulfasalazine for RA.
500 mg - 3 g daily
What to do if NSAIDs do not provide adequate symptom control?
Consider alternative NSAID
Review DMARD dose, consider change if no improvement
Consider short-term systemic steroid
How to manage the nausea and vomiting in patients taking methotrexate?
Folic acid
Add anti-emetic therapy
Change to parenteral MTX (if applicable)
How to manage disease flares when withdrawing systemic steroids?
Slower regimen
Consider reduce dose to lowest possible - only if withdrawal is impossible
How to manage the side-effects from long-term steroid treatment?
PPI, bisphosphonates and calcium + vitamin D preparations
Name examples of biological DMARDs used in third-line of RA management
Sarilumab
adalimumab
etanercept
infliximab
Which biological DMARDs are associated with stinging sensation at injection site?
adalimumab
etanercept
What is the solution for patients who cannot tolerate the stinging sensation of biological DMARDs administration?
Switch to infliximab
What is DAS28 score used for?
Used to consider the EULAR response of patients
Based on improvement in DAS28 score from baseline and DAS28 at endpoint
What aspects are taken into account of DAS28 score?
Number of joint tender
Number of joint swollen
ESR value
CRP value
Patient Global Health Input from HAQ
What is HAQ?
Health Assessment Questionaire
What are the risk factors of osteoarthritis?
Age
Obesity
Genetic components
Trauma and injuries
What causes the development of OA?
Imbalance between reparative and erosive processes in joint
Increase in proteolytic enzyme activity
Loss of cartilage around the joint
Bone outgrowths at joint margins -> harden -> deforming joint
What are the clinical features of OA?
Pain increases by activity, movement, loading of joints
Radiating pain
Stiffness in the morning - after rest - last less than 30 mins
Deformed joints
Who will not need clinical imaging investigation for the diagnosis of OA?
Older than 45 years old
Activity-related joint pain
No morning stiffness
Stiffness last less than 30 mins
No signs and symptoms of RA or gout
What are the core treatments for OA?
Therapeutic exercise
Weight management
Information and support
What information should the patients know about the therapeutic exercise for OA?
Might initially cause pain and discomfort
Long-term: reduce pain + improve functions
Besides the core treatment, name some adjunct treatments for OA patients.
Mannual therapy
Devices - walking aid
Pharmacological management - lowest effective dose for shortest time
What cases of OA that the patients can be considered for mannual therapy?
Hip and knee OA
What treatment that OA patients must NOT be offered by HCPs?
Acupuncture
Electrotherapy treatments
Routine insoles, braces, tapes, splints
What drugs should be recommended for OA patients?
Topical NSAID for knee OA
Consider topical NSAID for other OA-affected joints
If not work or unsuitable: oral NSAID + gastroprotective (PPIs)
Can consider intra-articular corticosteroid for short-term relief - only if other treatments are ineffective
What are the risk factors of gout?
Age
Dominant in males
Diet (red meat, seafood, alcoho)
Obesity
Genetic predispositions
Certain medications
Certain conditions
What are the medications that put patients at increased risk of gout?
thiazide and loop diuretics
ciclosporins
levodopa
What conditions are associated with increased risk of gout?
renal disease
diabetes
dyslipidaemia
hypertension
Causes of gout.
deposition of sodium urate crystals
precipitated from chronic hyperuricaemia
Why does gout normally attack the joints at extremities?
lower temperature -> easier to precipitate
Clinical features of gout.
No stiffness
Acute attack at big toe,
Painful, hot and red joint
Presence of tophi
Fever, elevated ESR
Prodromal symptoms before acute attack
What is tophi?
Bump of yellow uric crystals under the skin
Restrict the joint movement
What patients should be suspected with gout?
Rapid onset of severe pain + redness + swelling - MTP joints
If not MTP joints, consider
Tophi
What level of serum urate confirm the diagnosis of gout?
More than 360 micromol/l or 6 mg/dl
If less during a flare or strongly suspected, measure again at least 2 weeks later
What are the methods that can be used for diagnosis?
Present with symptoms
Confirm wih serum urate level
Joint aspiration + microscopy of synovial fluid
Imaging techniques (X-ray, ultrasound, CT)
How is acute gout flares managed?
1st-line: NSAID, colchicine, short-course of PO corticosteroids + PPIs (if needed)
2nd-line: intra-articular or IM corticosteroid
3rd-line: refer for an IL-1 inhibitor
Apply ice packs in addition to meds
What cases should the patients be referred toc rheumatology?
Diagnosis uncertain
CI treatment, not tolerated or ineffective
CKD stages 3b to 5
Had organ transplant
Who should be offered long-term urate lowering therapy (ULT)?
Multiple + troublesome flares
CKD stages 3 to 5
Diuretic therapy
Tophi
Chronic gouty arthritis
Define the concept of treat-to-target therapy
Start with low dose ULT
Measure urate levels monthly
Adjust dose according to measurements
When should the long-term ULT be started?
2 - 4 weeks after a gout flare has settled
If flares more frequent, ULT can start during a flare
Should patients who have reached target serum level continue to have ULT?
ULT tends to be life-long treatment
Discuss and consider with patients about benefit-risks before start or titrate
Annual monitoring of serum urate level
What is the target serum urate level?
Below 360 micromol/l or 6 mg/dl
Below 300 micromol/l or 5 dl for:
+ Tophi or chronic gouty arthritis
+ Ongoing frequent flares.
What are the drug choices for ULT?
1st-line: allopurinol or febuxostate. If major CVD, allopurinol
2nd-line: switch to other option
What information should be patients know when starting ULTs?
Induce attack at the start - must NOT stop the meds
What medications should be given to manage the therapy-induced flares?
1st-line: colchicine
2-nd line: low-dose NSAID or PO corticosteroid + PPIs
3-rd line: IL-1 inhibitor (need referral)
What is the main conncern for patients starting on allopurinol and febuxostat?
Development of rash -> withdraw immediately (Stevens-Johnson syndrome)
For allopurinol, if mild rash, gradually re-introduce -> if rash occurs -> STOP
Why alcohol increases the risk of gout?
Beer contains large quantities of purines from fermentation
Alcohol convert to lactic acid -> interfere with uric acid removal
Roles of ligament?
connecting bones together
prevent abnormal movement of the joint
give the joints the strength and stability
Roles of tendon?
Work as one unit with muscle
connecting muscles to bones
What is bursa?
small fluid-filled sac
reduce friction and protect tissues and bones (tendone-bones, tendon-tendon, skin-bones)
What are the most common symptoms for all musculoskeletal conditions?
Inflammation
Swelling
Pain
What are the four common causes for musculoskeletal conditions?
Wear and tear of soft tissues or bones
Straining - used in uncustomed way
Overuse - chronic or acute
Trauma - associated with acute
What can be used to distinguish between acute and chronic musculoskeletal conditions?
Assessing patterns
History of symptoms
Chronic tends to have systemic effects - fever, fatigue, aura
What is the common cause of the pain in conditions at the neck?
Straining of ligaments and muscles
Uncustomed movements
Wrong positions over long period of time
What causes acute torticollis - wry neck?
Spasm of neck muscle - from wrongly twisted or bent
Painful, one-sided, acute
Self-limiting conditions
What causes arthritis at neck?
Wear and tear of muscles
Gradual onset
Pain on both sides or one direction
What is the most common muscoskeletal condition in the shoulder?
Capsulitis - Frozen shoulder
What causes capsulitis?
Inflammation of tendons around the joints in the shoulder
Overused or uncustomised movement
How does capsulitis affect the patients?
Restricted movement in one or all movement
After heal -> can be restricted
Why can the shoulder still be restricted even the patients have healed from capsulitis?
Scarring of tissues
Fibrosis of muscle and tendon
-> chronic damage
If a patient is present with upper back pain, what conditions should be considered to rule out first?
cardiovascular cause - pain radiating from thoracic area
Excluding the CVS cause, what is the common cause of upper back pain?
Coughing
Lifting too heavy item
Result: straining of intercostal muscles between the ribs
How is the pain the patients will experience with upper back pain?
Sharpf pain in defined area
Worsening with breathing or coughing
When should the patients with upper back pain be referred?
CVS cause
Affected breathing severely, sharp continous pain - risk of PE
What is lumbago?
Lower back pain, normally not at rest or on slow movement
Straining of spinal muscles and ligaments
Is lumbago severe?
Mild - common in 30s and 40s
Severe if associated wtih vertebrae, discs and joint
When should the patients with lumbago be refered?
Severe
or
Last more than 3 - 4 weeks
What is the roles of discs in between the vertebrae of the spinal chord?
minimise friction between vertebrae
prevent wear and tear
What is sciata?
Prolapsed disc
Content of disc start shifting
Gel inside push through the hard outercasing
Impinge nerve root -> sudden severe back pain
How does the pain associated with sciata feel like?
sudden severe pain
affect walking
radiate to legs - neuropathic pain
pain even when sitting
What signs and symptoms shoud indicate sciata?
unilateral leg pain - radiating below knee -> foot/toes
low back pain with less severe leg pain
signs of nerve root compression
What are the signs of nerve root compression?
Tingling, numbness, muscle weakness in the distribution of nerve root
Painful when raising straight leg
Extensor plantar response
How long does sciata last?
4- 6 weeks
Can be longer
Pharmacological management of lower back pain and sciata?
1st-line: Ibuprofen or Naproxen + PPIs
2nd-line: Codeine with/without Paracetamol
NOT offer paracetamol alone
Self-management of sciata
Application of heat
Small firm cushion betweenn the knees or prop up knees
Simple exercise
Stay active + resume normal activities
What is ankylosing spondylitis?
inflammatory arthritis of the lumbar spine + joints in the sacral area
Fusion between vertebrae overtime
What drives the fusion between vertebrae in alkylosing spondylitis?
inflammation of ligaments
calcification where ligaments attached to bones
Symptoms of alkylosing spondylitis.
stiffness + discomfort
worse after rest, in the morning
better with exercise
What is coccygitis?
Inflammation and pain in the coccyx - end of spinal column
How does coccygitis arise?
Usually after a fall on hard surface
trauma to coccyx area
Symptoms of coccygitis.
painful
tender to touch
difficulty sitting down
Differential diagnosis of back pain
Kidneys and UTIs - associated with systemic symptoms like fever, blood in urine
Period pain
Pain from change bowel habit and weight loss -> suggest large intestine problem
Malignant tumour or tumour remission
Similarity and differences of tennis’s elbow and golfer’s elbow
Cause: overuse or uncustomed -> straning of tendons in forearms
Both self-limting with rest
Differences:
Tennis’s elbow - pulling action (outer muscle and tendon) - pain outside of arm
Golfer’s elbow - gripping action (inside tendon) - pain inside of arms
When should the patients with tennis’s or golfer’s elbow be refered?
last more than 2 - 3 weeks
Can patients with tennis’s or golfer’s elbow play sports again?
Yes with using some kind of support to reduce injuries risk
What is bursitis?
Student’s elbow - repeated flexing or persistent leaning on elbow -> inflammation of bursa
Pain and tenderness over tip of elbow
Pain on both rest and movement
What is Carpel Tunnel Syndrome?
inflammation of ligament system called carpel tunnel
Compression of median nerve
Symptoms of carpel tunnel syndrome.
pain
tenderness
numbness inside forearms, palms, fingers and wrists
Management of carpel tunnel syndrome.
Wrist support with rigid metal splint - 1st line -> keep at neutral angle -> allow healing
Steroid injection -> reduce inflammation + reduce pressure on the nerve
Surgery -> cutiting affected ligament -> reduce compression -> function regains
If the patients have carpel tunnel syndrome on both hands, how are they treated?
One arm at a time
Preserve function of one arm while other is recovering
What are the most common conditions affecting upper legs?
Pain from sciata
Strain or rupture of thigh muscles - sport, injuries -> self-limiting
What are the most common conditions affecting the knee?
Housemaid’s knee -> front bursitis
Baker’s cyst -> back bursitis
Sport or activity-related injuries
What is the most common conditions affecting the lower legsS
Rupture of tendon -> Achilles tendon.
Describe the severity of tendon rupture on patients.
Ruptured completely -> cannot walk
Partially ruptured or inflammed -> hard to stand on tiptoe or wearing heels
Pharmacy action towards rupture of Achilles tendon.
Referral
What are the drugs that can increase the risk of tendon rupture?
Fluoroquinolones antibiotics (ciprofloxacin)
Corticosteroids
Aromatase inhibitors
Statins
What are the most common conditions affecting the ankles?
Strain -> sport- or activity related injuries
What is the difference between a sprain and a strain?
Strain - overstretching of tendon
Sprain - overstretching of ligament
What are the most common conditions affecting the foot?
Bursitis - pain at back of the heel or under the heel
Plantar fascitis (Policeman’s Heel)
How does Policeman’s Heel (Plantar fascitis) develop?
Arch ligaments stretched or damaged
Pain under the sole, can radiate to whole foot
Relieved on rest and worse on tip-toe
What is often used to support patients with plantar fascitis?
orthotic insoles - give rest to arch
When should patients with plantar fascitis be referred?
More than 6 weeks
What are the warning signs of bruising?
Unexplained, frequent and excessive
Known clotting problems
Hepatic impairments
Taking drugs like warfarin, NSAIDs, steroids, carbimazole, methotrexate
What are the drugs that can cause bruising?
Warfarin
Antiplatelets
NSAIDs
Steroids
Carbimazole
Methotrexate
Muscoskeletal presence that require referral to A&E
Suspected fracture
Bony deformity or abnormality
Severe pain, tenderness bone
Can NOT bear weight
Widespread or worsening weakness
Immobilised joint
Muscoskeletal presence that require referral either to A&E or GP dependent on professional judgement.
Pain at rest or worsen at rest
No response to treatment
No improvement after 5 - 7 days
Gait disturbance
Bladder or bowel problems
Weight loss
Numbness or tingling
Elderly or children
Infection signs
Name the medications that are associated with muscoskeletal symptoms.
<hint: 6>
Statin -> myopathy
Ciprofloxacin and fluoroquinolones - tendon atrophy -> rupture
Analgesics - mask severity
Captopril -> arthralgia and myalgia
Immunosuppressant (including steroids) - muscle cramps, myalgia, arthralgia
Bruising-associated drugs
In the first 72 hours upon acute injuries, what is the management for patients?
Follow PRICE and avoid HARM
PRICE stands for =
Protection
Rest
Ice
Compression
Elevation
Explain how Ice and Compression would be effective in manage acute injuries?
Ice -> vasoconstriction -> less blood flow to areas -> reduce swelling and inflammation
Compression - limit space for fluid to accumulate -> reduce swelling
Explain how elevation would be effective in management of acute injuries?
Limbs above heart level -> remove excessive fluid into circulation -> avoid accummulation
HARM =
Heat
Alcohol
Running
Massage
Why does heat and alcohol should be avoided at the first 72 hours within injuries?
Vasodilation -> swelling
Reduce healing speed
Analgesia used in acute injuries
ORAL:
1st line = paracetamol
2nd-line = Ibuprofen 48 hours later
TOPICAL:
NSAIDs - must not used with oral NSAIDs
Acute muscoskeletal injuries manageemnt
First 72 hours:
- follow PRICE, avoid HARM
- Use analgesic to manage pain
After 72 hours:
- Heat
- Counter irritants (rubefacients) introduced
All time: forms of support
Define rubefacients.
Produce local vasodilation -> feeling of warm
Distract nervous system, block pain signals and mask perception of pain
Examples of rubefacients
Methyl salicylate, nicotinates, capsaicin, turpentine oil, camphor, menthol
What are the support forms that can be given to patients with muscoskeletal conditions?
Tubigrips - beneficial and necessary for all patients
Elasticated support - more necessary for chronic conditions
Neoprene support - compression and control temp in the joint
What can be used to manage bruising?
Heparinoid
Hyaluronidase
Arnica, Witch Hazels (mixed evidences - herbal product)
Describe how heparinoid and hyaluronidase can help with bruising.
Disperse oedema -> take blood causing fluid out.
Avoid if possibility of infection.
