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PHAY00010 > Clinical Pharmacy II > Flashcards

Clinical Pharmacy II Flashcards

Muscoskeletal conditions

1
Q

What are the risk factors of rheumatoid arthritis?

A

Gender (female higher risk)

Age (40-60) - can occur in children

Genetics - associated with HLA-DR4 allele

Cigarette smoking

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2
Q

How does rheumatoid arthritis arise?

A

Increase in number of inflammatory cells

Release cytokines -> proteolytic enzymes -> destruction of bone and cartilage

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3
Q

Clinical features of rheumatoid arthritis (symptoms and signs)

A

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

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4
Q

Why does the ESR reading increase in rheumatoid arthritis?

A

Inflammation -> produced proteins -> affect the repellant surface of RBC

RBC can stack easier -> faster rate of settlement -> higher ESR value

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5
Q

How is rheumatoid arthritis diagnosed?

A

No specific test

Suspected -> refer

Use some tests to speed up the diagnostic processes -> act like baseline measurement before treatment.

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6
Q

What are the tests that can be used as baseline measurement for the diagnosis and treatment monitoring of rheumatoid arthritis?

A

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

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7
Q

What is anti-CCP IG and antinuclear Ig? How are they related to RA?

A

Antinuclear Ig - linked with connective tissue diseases

Anti-CCP Ig = anti-cyclic citrullinated peptide Ig - chronic inflammation produced Ig

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8
Q

What type of anaemia in rheumatoid disease?

A

Secondary anaemia

Number of immature RBC is normal or low

Morpholgy of bone marrow normal

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9
Q

What are the differences between anaemia of chronic disease and iron deficiency anaemia (IDA), in terms of blood measurement?

A

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)

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10
Q

Explain the trend of ferritin level, serum level and transferrin level in chronic disease anaemia.

A

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)

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11
Q

What are the three management approach for RA?

A

Non-pharmacological treatment

Drug treatment

Surgical treatment

Can be combine or mono

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12
Q

What is the target of treating active RA in adults?

A

Treat-to-target therapy

Achieve target remission OR low disease activity if remission is impossible

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13
Q

Name the classes of drugs that need to be used for RA management

A

cDMARDs (conventional disease-modifying anti-rheumatic drugs)

biological DMARDs

NSAIDs, PPIs, glucocorticoids - symptom control

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14
Q

Describe the clinical management of active RA (first-line etc).

A

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

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15
Q

What is the consideration when switching cDMARDs?

A

Bridging therapy with glucocorticosteroids (short-term)

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16
Q

How is RA classed severe?

A

Das28 score above 5.1

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17
Q

What criteria is used to assess if the response to treatment is adequate?

A

EULAR criteria

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18
Q

Name cDMARDs used to manage RA in first and second-line

A

Methotrexate and sulfasalazine (most tolerated)

Gold (auranofin, sodium aurothionate)

Penicillamine

Hydroxychloroquine

Ciclosproins

Azathioprine

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19
Q

Monitoring requirements for cDMARDs

A

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

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20
Q

Why is FBC required to be monitored during RA treatment?

A

Most of the drugs cause myelosuppression - reduced blood cells production

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21
Q

Dose of methotrexate for RA.

A

7.5 - 22.5 mg once weekly

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22
Q

Dose of sulfasalazine for RA.

A

500 mg - 3 g daily

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23
Q

What to do if NSAIDs do not provide adequate symptom control?

A

Consider alternative NSAID

Review DMARD dose, consider change if no improvement

Consider short-term systemic steroid

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24
Q

How to manage the nausea and vomiting in patients taking methotrexate?

A

Folic acid

Add anti-emetic therapy

Change to parenteral MTX (if applicable)

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25
Q

How to manage disease flares when withdrawing systemic steroids?

A

Slower regimen

Consider reduce dose to lowest possible - only if withdrawal is impossible

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26
Q

How to manage the side-effects from long-term steroid treatment?

A

PPI, bisphosphonates and calcium + vitamin D preparations

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27
Q

Name examples of biological DMARDs used in third-line of RA management

A

Sarilumab

adalimumab

etanercept

infliximab

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28
Q

Which biological DMARDs are associated with stinging sensation at injection site?

A

adalimumab

etanercept

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29
Q

What is the solution for patients who cannot tolerate the stinging sensation of biological DMARDs administration?

A

Switch to infliximab

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30
Q

What is DAS28 score used for?

A

Used to consider the EULAR response of patients

Based on improvement in DAS28 score from baseline and DAS28 at endpoint

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31
Q

What aspects are taken into account of DAS28 score?

A

Number of joint tender

Number of joint swollen

ESR value

CRP value

Patient Global Health Input from HAQ

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32
Q

What is HAQ?

A

Health Assessment Questionaire

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33
Q

What are the risk factors of osteoarthritis?

A

Age

Obesity

Genetic components

Trauma and injuries

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34
Q

What causes the development of OA?

A

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

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35
Q

What are the clinical features of OA?

A

Pain increases by activity, movement, loading of joints

Radiating pain

Stiffness in the morning - after rest - last less than 30 mins

Deformed joints

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36
Q

Who will not need clinical imaging investigation for the diagnosis of OA?

A

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

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37
Q

What are the core treatments for OA?

A

Therapeutic exercise

Weight management

Information and support

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38
Q

What information should the patients know about the therapeutic exercise for OA?

A

Might initially cause pain and discomfort

Long-term: reduce pain + improve functions

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39
Q

Besides the core treatment, name some adjunct treatments for OA patients.

A

Mannual therapy

Devices - walking aid

Pharmacological management - lowest effective dose for shortest time

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40
Q

What cases of OA that the patients can be considered for mannual therapy?

A

Hip and knee OA

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41
Q

What treatment that OA patients must NOT be offered by HCPs?

A

Acupuncture

Electrotherapy treatments

Routine insoles, braces, tapes, splints

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42
Q

What drugs should be recommended for OA patients?

A

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

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43
Q

What are the risk factors of gout?

A

Age

Dominant in males

Diet (red meat, seafood, alcoho)

Obesity

Genetic predispositions

Certain medications

Certain conditions

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44
Q

What are the medications that put patients at increased risk of gout?

A

thiazide and loop diuretics

ciclosporins

levodopa

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45
Q

What conditions are associated with increased risk of gout?

A

renal disease

diabetes

dyslipidaemia

hypertension

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46
Q

Causes of gout.

A

deposition of sodium urate crystals

precipitated from chronic hyperuricaemia

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47
Q

Why does gout normally attack the joints at extremities?

A

lower temperature -> easier to precipitate

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48
Q

Clinical features of gout.

A

No stiffness

Acute attack at big toe,

Painful, hot and red joint

Presence of tophi

Fever, elevated ESR

Prodromal symptoms before acute attack

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49
Q

What is tophi?

A

Bump of yellow uric crystals under the skin

Restrict the joint movement

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50
Q

What patients should be suspected with gout?

A

Rapid onset of severe pain + redness + swelling - MTP joints

If not MTP joints, consider

Tophi

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51
Q

What level of serum urate confirm the diagnosis of gout?

A

More than 360 micromol/l or 6 mg/dl

If less during a flare or strongly suspected, measure again at least 2 weeks later

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52
Q

What are the methods that can be used for diagnosis?

A

Present with symptoms

Confirm wih serum urate level

Joint aspiration + microscopy of synovial fluid

Imaging techniques (X-ray, ultrasound, CT)

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53
Q

How is acute gout flares managed?

A

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

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54
Q

What cases should the patients be referred toc rheumatology?

A

Diagnosis uncertain

CI treatment, not tolerated or ineffective

CKD stages 3b to 5

Had organ transplant

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55
Q

Who should be offered long-term urate lowering therapy (ULT)?

A

Multiple + troublesome flares

CKD stages 3 to 5

Diuretic therapy

Tophi

Chronic gouty arthritis

56
Q

Define the concept of treat-to-target therapy

A

Start with low dose ULT

Measure urate levels monthly

Adjust dose according to measurements

57
Q

When should the long-term ULT be started?

A

2 - 4 weeks after a gout flare has settled

If flares more frequent, ULT can start during a flare

58
Q

Should patients who have reached target serum level continue to have ULT?

A

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

59
Q

What is the target serum urate level?

A

Below 360 micromol/l or 6 mg/dl

Below 300 micromol/l or 5 dl for:
+ Tophi or chronic gouty arthritis
+ Ongoing frequent flares.

60
Q

What are the drug choices for ULT?

A

1st-line: allopurinol or febuxostate. If major CVD, allopurinol

2nd-line: switch to other option

61
Q

What information should be patients know when starting ULTs?

A

Induce attack at the start - must NOT stop the meds

62
Q

What medications should be given to manage the therapy-induced flares?

A

1st-line: colchicine

2-nd line: low-dose NSAID or PO corticosteroid + PPIs

3-rd line: IL-1 inhibitor (need referral)

63
Q

What is the main conncern for patients starting on allopurinol and febuxostat?

A

Development of rash -> withdraw immediately (Stevens-Johnson syndrome)

For allopurinol, if mild rash, gradually re-introduce -> if rash occurs -> STOP

64
Q

Why alcohol increases the risk of gout?

A

Beer contains large quantities of purines from fermentation

Alcohol convert to lactic acid -> interfere with uric acid removal

65
Q

Roles of ligament?

A

connecting bones together

prevent abnormal movement of the joint

give the joints the strength and stability

66
Q

Roles of tendon?

A

Work as one unit with muscle

connecting muscles to bones

67
Q

What is bursa?

A

small fluid-filled sac

reduce friction and protect tissues and bones (tendone-bones, tendon-tendon, skin-bones)

68
Q

What are the most common symptoms for all musculoskeletal conditions?

A

Inflammation

Swelling

Pain

69
Q

What are the four common causes for musculoskeletal conditions?

A

Wear and tear of soft tissues or bones

Straining - used in uncustomed way

Overuse - chronic or acute

Trauma - associated with acute

70
Q

What can be used to distinguish between acute and chronic musculoskeletal conditions?

A

Assessing patterns

History of symptoms

Chronic tends to have systemic effects - fever, fatigue, aura

71
Q

What is the common cause of the pain in conditions at the neck?

A

Straining of ligaments and muscles

Uncustomed movements

Wrong positions over long period of time

72
Q

What causes acute torticollis - wry neck?

A

Spasm of neck muscle - from wrongly twisted or bent

Painful, one-sided, acute

Self-limiting conditions

73
Q

What causes arthritis at neck?

A

Wear and tear of muscles

Gradual onset

Pain on both sides or one direction

74
Q

What is the most common muscoskeletal condition in the shoulder?

A

Capsulitis - Frozen shoulder

75
Q

What causes capsulitis?

A

Inflammation of tendons around the joints in the shoulder

Overused or uncustomised movement

76
Q

How does capsulitis affect the patients?

A

Restricted movement in one or all movement

After heal -> can be restricted

77
Q

Why can the shoulder still be restricted even the patients have healed from capsulitis?

A

Scarring of tissues

Fibrosis of muscle and tendon

-> chronic damage

78
Q

If a patient is present with upper back pain, what conditions should be considered to rule out first?

A

cardiovascular cause - pain radiating from thoracic area

79
Q

Excluding the CVS cause, what is the common cause of upper back pain?

A

Coughing

Lifting too heavy item

Result: straining of intercostal muscles between the ribs

80
Q

How is the pain the patients will experience with upper back pain?

A

Sharpf pain in defined area

Worsening with breathing or coughing

81
Q

When should the patients with upper back pain be referred?

A

CVS cause

Affected breathing severely, sharp continous pain - risk of PE

82
Q

What is lumbago?

A

Lower back pain, normally not at rest or on slow movement

Straining of spinal muscles and ligaments

83
Q

Is lumbago severe?

A

Mild - common in 30s and 40s

Severe if associated wtih vertebrae, discs and joint

84
Q

When should the patients with lumbago be refered?

A

Severe

or

Last more than 3 - 4 weeks

85
Q

What is the roles of discs in between the vertebrae of the spinal chord?

A

minimise friction between vertebrae

prevent wear and tear

86
Q

What is sciata?

A

Prolapsed disc

Content of disc start shifting

Gel inside push through the hard outercasing

Impinge nerve root -> sudden severe back pain

87
Q

How does the pain associated with sciata feel like?

A

sudden severe pain

affect walking

radiate to legs - neuropathic pain

pain even when sitting

88
Q

What signs and symptoms shoud indicate sciata?

A

unilateral leg pain - radiating below knee -> foot/toes

low back pain with less severe leg pain

signs of nerve root compression

89
Q

What are the signs of nerve root compression?

A

Tingling, numbness, muscle weakness in the distribution of nerve root

Painful when raising straight leg

Extensor plantar response

90
Q

How long does sciata last?

A

4- 6 weeks

Can be longer

91
Q

Pharmacological management of lower back pain and sciata?

A

1st-line: Ibuprofen or Naproxen + PPIs

2nd-line: Codeine with/without Paracetamol

NOT offer paracetamol alone

92
Q

Self-management of sciata

A

Application of heat

Small firm cushion betweenn the knees or prop up knees

Simple exercise

Stay active + resume normal activities

93
Q

What is ankylosing spondylitis?

A

inflammatory arthritis of the lumbar spine + joints in the sacral area

Fusion between vertebrae overtime

94
Q

What drives the fusion between vertebrae in alkylosing spondylitis?

A

inflammation of ligaments

calcification where ligaments attached to bones

95
Q

Symptoms of alkylosing spondylitis.

A

stiffness + discomfort

worse after rest, in the morning

better with exercise

96
Q

What is coccygitis?

A

Inflammation and pain in the coccyx - end of spinal column

97
Q

How does coccygitis arise?

A

Usually after a fall on hard surface

trauma to coccyx area

98
Q

Symptoms of coccygitis.

A

painful

tender to touch

difficulty sitting down

99
Q

Differential diagnosis of back pain

A

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

100
Q

Similarity and differences of tennis’s elbow and golfer’s elbow

A

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

101
Q

When should the patients with tennis’s or golfer’s elbow be refered?

A

last more than 2 - 3 weeks

102
Q

Can patients with tennis’s or golfer’s elbow play sports again?

A

Yes with using some kind of support to reduce injuries risk

103
Q

What is bursitis?

A

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

104
Q

What is Carpel Tunnel Syndrome?

A

inflammation of ligament system called carpel tunnel

Compression of median nerve

105
Q

Symptoms of carpel tunnel syndrome.

A

pain

tenderness

numbness inside forearms, palms, fingers and wrists

106
Q

Management of carpel tunnel syndrome.

A

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

107
Q

If the patients have carpel tunnel syndrome on both hands, how are they treated?

A

One arm at a time

Preserve function of one arm while other is recovering

108
Q

What are the most common conditions affecting upper legs?

A

Pain from sciata

Strain or rupture of thigh muscles - sport, injuries -> self-limiting

109
Q

What are the most common conditions affecting the knee?

A

Housemaid’s knee -> front bursitis

Baker’s cyst -> back bursitis

Sport or activity-related injuries

110
Q

What is the most common conditions affecting the lower legsS

A

Rupture of tendon -> Achilles tendon.

111
Q

Describe the severity of tendon rupture on patients.

A

Ruptured completely -> cannot walk

Partially ruptured or inflammed -> hard to stand on tiptoe or wearing heels

112
Q

Pharmacy action towards rupture of Achilles tendon.

A

Referral

113
Q

What are the drugs that can increase the risk of tendon rupture?

A

Fluoroquinolones antibiotics (ciprofloxacin)

Corticosteroids

Aromatase inhibitors

Statins

114
Q

What are the most common conditions affecting the ankles?

A

Strain -> sport- or activity related injuries

115
Q

What is the difference between a sprain and a strain?

A

Strain - overstretching of tendon

Sprain - overstretching of ligament

116
Q

What are the most common conditions affecting the foot?

A

Bursitis - pain at back of the heel or under the heel

Plantar fascitis (Policeman’s Heel)

117
Q

How does Policeman’s Heel (Plantar fascitis) develop?

A

Arch ligaments stretched or damaged

Pain under the sole, can radiate to whole foot

Relieved on rest and worse on tip-toe

118
Q

What is often used to support patients with plantar fascitis?

A

orthotic insoles - give rest to arch

119
Q

When should patients with plantar fascitis be referred?

A

More than 6 weeks

120
Q

What are the warning signs of bruising?

A

Unexplained, frequent and excessive

Known clotting problems

Hepatic impairments

Taking drugs like warfarin, NSAIDs, steroids, carbimazole, methotrexate

121
Q

What are the drugs that can cause bruising?

A

Warfarin

Antiplatelets

NSAIDs

Steroids

Carbimazole

Methotrexate

122
Q

Muscoskeletal presence that require referral to A&E

A

Suspected fracture

Bony deformity or abnormality

Severe pain, tenderness bone

Can NOT bear weight

Widespread or worsening weakness

Immobilised joint

123
Q

Muscoskeletal presence that require referral either to A&E or GP dependent on professional judgement.

A

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

124
Q

Name the medications that are associated with muscoskeletal symptoms.

<hint: 6>

A

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

125
Q

In the first 72 hours upon acute injuries, what is the management for patients?

A

Follow PRICE and avoid HARM

126
Q

PRICE stands for =

A

Protection
Rest
Ice
Compression
Elevation

127
Q

Explain how Ice and Compression would be effective in manage acute injuries?

A

Ice -> vasoconstriction -> less blood flow to areas -> reduce swelling and inflammation

Compression - limit space for fluid to accumulate -> reduce swelling

128
Q

Explain how elevation would be effective in management of acute injuries?

A

Limbs above heart level -> remove excessive fluid into circulation -> avoid accummulation

129
Q

HARM =

A

Heat

Alcohol

Running

Massage

130
Q

Why does heat and alcohol should be avoided at the first 72 hours within injuries?

A

Vasodilation -> swelling

Reduce healing speed

131
Q

Analgesia used in acute injuries

A

ORAL:
1st line = paracetamol

2nd-line = Ibuprofen 48 hours later

TOPICAL:
NSAIDs - must not used with oral NSAIDs

132
Q

Acute muscoskeletal injuries manageemnt

A

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

133
Q

Define rubefacients.

A

Produce local vasodilation -> feeling of warm

Distract nervous system, block pain signals and mask perception of pain

134
Q

Examples of rubefacients

A

Methyl salicylate, nicotinates, capsaicin, turpentine oil, camphor, menthol

135
Q

What are the support forms that can be given to patients with muscoskeletal conditions?

A

Tubigrips - beneficial and necessary for all patients

Elasticated support - more necessary for chronic conditions

Neoprene support - compression and control temp in the joint

136
Q

What can be used to manage bruising?

A

Heparinoid

Hyaluronidase

Arnica, Witch Hazels (mixed evidences - herbal product)

137
Q

Describe how heparinoid and hyaluronidase can help with bruising.

A

Disperse oedema -> take blood causing fluid out.

Avoid if possibility of infection.

PHAY00010 (4 decks)

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