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PR3154 > IC16 - OARA > Flashcards

IC16 - OARA Flashcards

1
Q

When is urgent referral needed for joint pain?

A
  1. Infection
  2. Trauma
  3. Malignancy
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2
Q

What is osteoarthritis?

A

Degenerative disease with inflammation of bone and joint cartilage

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3
Q

List 3 risk factors that can lead to osteoarthritis.

A
  1. Joint injury
  2. Obesity
  3. Aging
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4
Q

Briefly outline the pathophysiology of osteoarthritis.

A
  1. Cartilage degradation due to weakening and degraded collagen matrix
  2. Bone remodeling and osteophyte formation causing thickened subchondral bone and widening of joint
  3. Synovial inflammation due to “shards” which lead to inflammatory components
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5
Q

What are the key features of osteoarthritis?

A
  1. Inflammation
  2. Morning Stiffness < 30 min
  3. Limited joint movement
  4. Functional limitation and instability
  5. Asymmetrical polyarthritis ( i.e. weight bearing joints - hands, knee, hip)
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6
Q

Patients with osteoarthritis have pain that is worse in _____.

A
  1. late afternoon or early evening
  2. Going down stairs
  3. Joint line
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7
Q

Pain in osteoarthritis has a ____ onset.

A

slow

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8
Q

What are the three disorders that is associated with osteoarthritis?

A
  1. Anxiety
  2. Depression
  3. Sleep disturbance
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9
Q

What is the first stage of osteoarthritis?

A
  1. Predictable pain with mechanical insult
  2. Limits high-impact activities
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10
Q

What is the second stage of osteoarthritis?

A
  1. Constant pain with unpredictable episodes of stiffness
  2. Affects daily activities
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11
Q

What is the third stage of osteoarthritis?

A
  1. Constant dull/ aching, intense and exhausting pain
  2. Severe limitation in functions
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12
Q

List three criteria patient needs to fulfil be diagnosed without imaging for OA.

A
  1. ≥45yo
  2. Activity-related joint pain (in one or few joints)
  3. Morning stiffness ≤ 30mins
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13
Q

When is additional testing considered in OA?

A
  1. Younger individuals
  2. Hx of recent trauma
  3. Rapidly worsening symptoms or deformity
  4. Concerns of infection or malignancy
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14
Q

What are the non-pharmacological treatments for OA?

A
  1. Exercise
  2. Weight management
  3. Information and support
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15
Q

List four types of medications that can be given to OA patients?

A
  1. Topical NSAIDs
  2. Oral NSAIDs/ coxib
  3. Oral paracetamol/ tramadol
  4. Intraarticular glucocorticoid injections
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16
Q

What are the risk factors associated with GI toxicity for NSAIDs?

A
  1. > 65yo
  2. Hx of ulcer
  3. Use of high dose/ chronic NSAID
  4. Concurrent GC/ antiplatelets/ anticoagulants
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17
Q

For OA patients with high risk of GI toxicity, what can be given?

A

COX 2 selective NSAIDs or add PPI to non-selective NSAIDs

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18
Q

When should NSAIDs not be given to OA patients with risk of renal toxicity?

A
  1. eGFR < 15
  2. Volume depletion
  3. Concurrent Aminoglycosides, Amp B and radiocontrast
  4. Concurrent Diuretics, ACEI/ ARB
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19
Q

What is the dose of tramadol that can be given if patient is contraindicated to all other medication and has moderate to severe pain?

A

25-50mg TDS (max 400mg/ day)

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20
Q

List 5 populations that cannot use intraarticular glucocorticoid injections.

A
  1. Periarticular infection
  2. Septic arthritis
  3. Periarticular #
  4. Joint instability
  5. Juxtaarticular osteoporosis
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21
Q

When is referral needed for surgical treatment in OA patients?

A
  1. QoL substantially affected
  2. Non-surgical tx is ineffective / unsuitable
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22
Q

What is RA?

A

Chronic autoimmune inflammatory systemic disease

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23
Q

What is the risk factor that is highly associated with RA?

A

Family history

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24
Q

Briefly discuss the pathophysiology of RA.

A

Genetic predisposition leads to immunologic trigger, leading to T cell mediated immune response and recruitment of proteases, inflammatory cytokines such as IL17, TNF, IL1 and IL6, and destruction of articular cartilage and underlying bone

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25
Q

What is clinical presentation of RA?

A
  1. Inflammation
  2. Early morning stiffness > 30 mins
  3. Symmetrical polyarthritis (small and large joints)
  4. Systemic symptoms
  5. Extra articular complications
26
Q

What occurs in chronic RA?

A

Deformities

27
Q

What are the pertinent laboratory findings in RA?

A
  1. RF (+ve)
  2. Anti-CCP assays (+ve)
  3. ESR (increase)
  4. CRP (increase)
28
Q

What are the goals of Tx of RA?

A
  1. Achieve remission or low disease activity (At least 6 months)
  2. Boolean 2.0 criteria (remission)
  3. Index based definition (DAS28)
29
Q

What are the two medication that can be given for RA?

A
  1. Glucocorticoids
  2. DMARDs
30
Q

NSAIDs do not ____ course of disease.

A

alter

31
Q

How is NSAIDs usually given for RA patients?

A
  1. Adjuncts
32
Q

What is the purpose of GC?

A
  1. Low-dose bridging therapy (PO prednisolone < 7.5mg/day)
33
Q

What is the duration for use of glucocorticoids in RA patients?

A

Repeated 3q monthly, but not more than 2-3x per year per joints

34
Q

DMARDs have ___ onset.

A

slow

35
Q

What is the DMARDs of choice for RA?

A

Methotrexate

36
Q

What are the two other medications that can be given if MTX is contraindicated or not tolerated in RA patients.

A

Sulfasalazine/ leflunomide

37
Q

When initiating or changing DMARDs, what can be given?

A

Short term GC

38
Q

When should treatment be adjusted in active disease state of RA?

A

No improvement by 3 mth/ target not reached by 6 mth

39
Q

What is the management for DMARD-naïve patients (RA) with moderate to high disease activity?

A
  1. Methotrexate monotherapy (7.5mg ONCE weekly + folic acid 5mg/week)
  2. If need short term GC, add
40
Q

What is the management for DMARD-naïve patients (RA) with low disease activity?

A

Hydroxychloroquine > Sulfasalazine > methotrexate > leflunomide

41
Q

What is one important counselling point that should be conveyed to patients taking methotrexate and folic acid?

A

Take Folic acid day after MTX

42
Q

When should glucocorticoid be removed from regimen if started?

A
  1. Gradual tapering within 3 months and discontinued
  2. Discontinued if bDMARD/tsDMARD started
43
Q

MTX should be avoided in RA patients when CrCl ______.

A

less than 30ml/min

44
Q

Which of the 2 cSDMARDs should be avoided in pregnancy?

A

MTX and Leflunomide

45
Q

Hydroxychloroquine can lead to ______.

A

retinopathy

46
Q

Hydroxychloroquine is contraindicated in RA patients with _____ and ____.

A
  1. Preexisting retinopathy
  2. Caution in G6PD deficiency
47
Q

Sulfasalazine is contraindicated in patients with ____ .

A

sulfonamide allergies

48
Q

List three S/E of MTX.

A
  1. Increase transaminases
  2. Myelosuppression
  3. TENS, SJS
49
Q

List the S/E of leflunomide.

A
  1. Increase transaminases
  2. Myelosuppression
  3. Alopecia
50
Q

List 1 DDI of Leflunomide.

A

Cholestyramine

51
Q

When should Leflunomide not be given to patients with liver dysfunction?

A

ALT>2x ULN

52
Q

What is the next step to contract if RA patients is not at target after using DMARD?

A
  1. Already on MTX: Add bDMARD or tsDMARD or hydroxychloroquine & sulfasalazine
  2. Already on bDMARD/tsDMARD: Switch to bDMARD or tsDMARD of a different class
53
Q

What are some monitoring parameters for bDMARDs and tsDMARDs?

A
  1. Myelosuppression: CBC
  2. Infections: pre-DMARD screening
  3. Cardiovascular diseases: HF (avoid TNF-𝛼 inhibitors in NYHA class III & IV)
  4. Hepatic effects: LFT
  5. Metabolic effects: lipid panel
  6. GI perforation: evaluate abdo pain or repeated vomiting
  7. Thrombosis: avoid in patients w Hx of thrombotic events esp JAK and IL6 inhibitors
54
Q

TNF-a inhibitors for RA may result in production of _____.

A

Anti-drug antibodies

55
Q

What is the prefered DMARD between bDMARD and tsDMARD?

A

bDMARD

56
Q

What is one risk of tofacitinib?

A

MACEs and malignancy

57
Q

When initiating bDMARDs or tsDAMRDs, what should be done?

A
  1. Pre-treatment screening: TB, Hepatitis B & C
  2. Vaccination before initiation: Pneumococcal, Influenza, Hepatitis B, Varicella zoster / Herpes zoster
  3. Laboratory: CBC w differential white count & platelet count, LFT, Lipid panel, SCr
58
Q

What is the management for RA patients on target for ≥ 6 months?

A
  1. Do NOT discontinue DMARD abruptly
  2. Continuation of all DMARDS recommended over reduction of dose/ gradual discontinuation.
59
Q

In triple therapy for RA , what is recommended to be discontinued?

A

Sulfasalazine

60
Q

In RA patients with MTX and bDMARD/tsDMARD, which is recommended to be discontiuned?

A

MTX

61
Q

List 2 important non-pharmacological interventions for RA patients.

A
  1. Rest inflamed joint
  2. Exercise but avoid high-intensity weight bearing exercises especially in those with structural damage of lower extremity joints

PR3154 (16 decks)

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