Clinical Pharmacy II Flashcards
Muscoskeletal conditions (137 cards)
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)