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Clinical Pharmacy II Flashcards

Muscoskeletal conditions (137 cards)

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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
How to manage disease flares when withdrawing systemic steroids?
Slower regimen Consider reduce dose to lowest possible - only if withdrawal is impossible
26
How to manage the side-effects from long-term steroid treatment?
PPI, bisphosphonates and calcium + vitamin D preparations
27
Name examples of biological DMARDs used in third-line of RA management
Sarilumab adalimumab etanercept infliximab
28
Which biological DMARDs are associated with stinging sensation at injection site?
adalimumab etanercept
29
What is the solution for patients who cannot tolerate the stinging sensation of biological DMARDs administration?
Switch to infliximab
30
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
31
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
32
What is HAQ?
Health Assessment Questionaire
33
What are the risk factors of osteoarthritis?
Age Obesity Genetic components Trauma and injuries
34
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
35
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
36
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
37
What are the core treatments for OA?
Therapeutic exercise Weight management Information and support
38
What information should the patients know about the therapeutic exercise for OA?
Might initially cause pain and discomfort Long-term: reduce pain + improve functions
39
Besides the core treatment, name some adjunct treatments for OA patients.
Mannual therapy Devices - walking aid Pharmacological management - lowest effective dose for shortest time
40
What cases of OA that the patients can be considered for mannual therapy?
Hip and knee OA
41
What treatment that OA patients must NOT be offered by HCPs?
Acupuncture Electrotherapy treatments Routine insoles, braces, tapes, splints
42
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
43
What are the risk factors of gout?
Age Dominant in males Diet (red meat, seafood, alcoho) Obesity Genetic predispositions Certain medications Certain conditions
44
What are the medications that put patients at increased risk of gout?
thiazide and loop diuretics ciclosporins levodopa
45
What conditions are associated with increased risk of gout?
renal disease diabetes dyslipidaemia hypertension
46
Causes of gout.
deposition of sodium urate crystals precipitated from chronic hyperuricaemia
47
Why does gout normally attack the joints at extremities?
lower temperature -> easier to precipitate
48
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
49
What is tophi?
Bump of yellow uric crystals under the skin Restrict the joint movement
50
What patients should be suspected with gout?
Rapid onset of severe pain + redness + swelling - MTP joints If not MTP joints, consider Tophi
51
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
52
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)
53
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
54
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
55
Who should be offered long-term urate lowering therapy (ULT)?
Multiple + troublesome flares CKD stages 3 to 5 Diuretic therapy Tophi Chronic gouty arthritis
56
Define the concept of treat-to-target therapy
Start with low dose ULT Measure urate levels monthly Adjust dose according to measurements
57
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
58
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
59
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.
60
What are the drug choices for ULT?
1st-line: allopurinol or febuxostate. If major CVD, allopurinol 2nd-line: switch to other option
61
What information should be patients know when starting ULTs?
Induce attack at the start - must NOT stop the meds
62
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)
63
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
64
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
65
Roles of ligament?
connecting bones together prevent abnormal movement of the joint give the joints the strength and stability
66
Roles of tendon?
Work as one unit with muscle connecting muscles to bones
67
What is bursa?
small fluid-filled sac reduce friction and protect tissues and bones (tendone-bones, tendon-tendon, skin-bones)
68
What are the most common symptoms for all musculoskeletal conditions?
Inflammation Swelling Pain
69
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
70
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
71
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
72
What causes acute torticollis - wry neck?
Spasm of neck muscle - from wrongly twisted or bent Painful, one-sided, acute Self-limiting conditions
73
What causes arthritis at neck?
Wear and tear of muscles Gradual onset Pain on both sides or one direction
74
What is the most common muscoskeletal condition in the shoulder?
Capsulitis - Frozen shoulder
75
What causes capsulitis?
Inflammation of tendons around the joints in the shoulder Overused or uncustomised movement
76
How does capsulitis affect the patients?
Restricted movement in one or all movement After heal -> can be restricted
77
Why can the shoulder still be restricted even the patients have healed from capsulitis?
Scarring of tissues Fibrosis of muscle and tendon -> chronic damage
78
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
79
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
80
How is the pain the patients will experience with upper back pain?
Sharpf pain in defined area Worsening with breathing or coughing
81
When should the patients with upper back pain be referred?
CVS cause Affected breathing severely, sharp continous pain - risk of PE
82
What is lumbago?
Lower back pain, normally not at rest or on slow movement Straining of spinal muscles and ligaments
83
Is lumbago severe?
Mild - common in 30s and 40s Severe if associated wtih vertebrae, discs and joint
84
When should the patients with lumbago be refered?
Severe or Last more than 3 - 4 weeks
85
What is the roles of discs in between the vertebrae of the spinal chord?
minimise friction between vertebrae prevent wear and tear
86
What is sciata?
Prolapsed disc Content of disc start shifting Gel inside push through the hard outercasing Impinge nerve root -> sudden severe back pain
87
How does the pain associated with sciata feel like?
sudden severe pain affect walking radiate to legs - neuropathic pain pain even when sitting
88
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
89
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
90
How long does sciata last?
4- 6 weeks Can be longer
91
Pharmacological management of lower back pain and sciata?
1st-line: Ibuprofen or Naproxen + PPIs 2nd-line: Codeine with/without Paracetamol NOT offer paracetamol alone
92
Self-management of sciata
Application of heat Small firm cushion betweenn the knees or prop up knees Simple exercise Stay active + resume normal activities
93
What is ankylosing spondylitis?
inflammatory arthritis of the lumbar spine + joints in the sacral area Fusion between vertebrae overtime
94
What drives the fusion between vertebrae in alkylosing spondylitis?
inflammation of ligaments calcification where ligaments attached to bones
95
Symptoms of alkylosing spondylitis.
stiffness + discomfort worse after rest, in the morning better with exercise
96
What is coccygitis?
Inflammation and pain in the coccyx - end of spinal column
97
How does coccygitis arise?
Usually after a fall on hard surface trauma to coccyx area
98
Symptoms of coccygitis.
painful tender to touch difficulty sitting down
99
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
100
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
101
When should the patients with tennis's or golfer's elbow be refered?
last more than 2 - 3 weeks
102
Can patients with tennis's or golfer's elbow play sports again?
Yes with using some kind of support to reduce injuries risk
103
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
104
What is Carpel Tunnel Syndrome?
inflammation of ligament system called carpel tunnel Compression of median nerve
105
Symptoms of carpel tunnel syndrome.
pain tenderness numbness inside forearms, palms, fingers and wrists
106
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
107
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
108
What are the most common conditions affecting upper legs?
Pain from sciata Strain or rupture of thigh muscles - sport, injuries -> self-limiting
109
What are the most common conditions affecting the knee?
Housemaid's knee -> front bursitis Baker's cyst -> back bursitis Sport or activity-related injuries
110
What is the most common conditions affecting the lower legsS
Rupture of tendon -> Achilles tendon.
111
Describe the severity of tendon rupture on patients.
Ruptured completely -> cannot walk Partially ruptured or inflammed -> hard to stand on tiptoe or wearing heels
112
Pharmacy action towards rupture of Achilles tendon.
Referral
113
What are the drugs that can increase the risk of tendon rupture?
Fluoroquinolones antibiotics (ciprofloxacin) Corticosteroids Aromatase inhibitors Statins
114
What are the most common conditions affecting the ankles?
Strain -> sport- or activity related injuries
115
What is the difference between a sprain and a strain?
Strain - overstretching of tendon Sprain - overstretching of ligament
116
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)
117
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
118
What is often used to support patients with plantar fascitis?
orthotic insoles - give rest to arch
119
When should patients with plantar fascitis be referred?
More than 6 weeks
120
What are the warning signs of bruising?
Unexplained, frequent and excessive Known clotting problems Hepatic impairments Taking drugs like warfarin, NSAIDs, steroids, carbimazole, methotrexate
121
What are the drugs that can cause bruising?
Warfarin Antiplatelets NSAIDs Steroids Carbimazole Methotrexate
122
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
123
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
124
Name the medications that are associated with muscoskeletal symptoms.
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
In the first 72 hours upon acute injuries, what is the management for patients?
Follow PRICE and avoid HARM
126
PRICE stands for =
Protection Rest Ice Compression Elevation
127
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
128
Explain how elevation would be effective in management of acute injuries?
Limbs above heart level -> remove excessive fluid into circulation -> avoid accummulation
129
HARM =
Heat Alcohol Running Massage
130
Why does heat and alcohol should be avoided at the first 72 hours within injuries?
Vasodilation -> swelling Reduce healing speed
131
Analgesia used in acute injuries
ORAL: 1st line = paracetamol 2nd-line = Ibuprofen 48 hours later TOPICAL: NSAIDs - must not used with oral NSAIDs
132
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
133
Define rubefacients.
Produce local vasodilation -> feeling of warm Distract nervous system, block pain signals and mask perception of pain
134
Examples of rubefacients
Methyl salicylate, nicotinates, capsaicin, turpentine oil, camphor, menthol
135
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
136
What can be used to manage bruising?
Heparinoid Hyaluronidase Arnica, Witch Hazels (mixed evidences - herbal product)
137
Describe how heparinoid and hyaluronidase can help with bruising.
Disperse oedema -> take blood causing fluid out. Avoid if possibility of infection.

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