MSK

Question 1

Arthritis

Answer 1

Pain, swelling and inflammation in the joints
Stiffness in one or more of the joints; usually the hands, feet and writs
Common types; osteoarthritis and rheumatoid arthritis
Other types; gout, psoriatic arthritis (psoriasis pts), ankylosing spondylitis (long term inflammation of spine), cervical spondylitis (age related wear and tear or trauma to spine disc in neck)
Symptoms; joint pain, tenderness and stiffness, inflammation in and around the joints, warm red skin, weakness and muscle wasting

Question 2

Rheumatoid arthritis

Answer 2

Autoimmune
Age of onset 20s till 40s
Speed of onset is rapid within weeks to months
Symmetrical polyarticular (small and large joints) affected
Effusion, redness and warmth of the joints and patient can feel malaise and fatigue
Morning stiffness lasts longer than 30 mins to an hour
Movement may improve joint pain
Pts also increased risk of CVD, osteoporosis, anaemia and infection

Question 3

Rheumatoid arthritis testing

Answer 3

ESR / CRP elevated
C reactive protein used to differentiate
RhF positive

Question 4

Osteoarthritis

Answer 4

Degenerative
Older ages (compared to RA), many years
Common type of arthritis; occurs when smooth cartilage lining joints start to roughen and thin out
Most commonly affected joints are in hands, spine, knees and hips; UNILATERALLY limited to one set of joints
Joint swelling bony no systemic symptoms
Morning stiffness lasts less than an hour
Movement may worsen joint pain
Bloods; ESR/CRP normal and RhF negative

Question 5

Rheumatoid arthritis drug treatment

Answer 5

DMARDs
Sulfasalazine
Azathioprine
Ciclosporin
Less commonl leflunomide, penicillamine, gold, antimalarials, cytokine modulators

Question 6

DMARDs

Answer 6

Disease modifying anti rheumatic drugs
Need to take 2-6 months to affect the progression of RA
Starting DMARD; could stop/reduce NSAID dose
Patients referred to limit joint damage

Question 7

Osteoarthritis treatment

Answer 7

1st line paracetamol
Topical NSAIDs or capsaicin 0.025% in knee / hand osteoarthritis
ORAL NSAID
If already taking aspirin then opioid
Recommendation weight reduction and exercise

Question 8

Methotrexate

Answer 8

Used in RA, cancer, psoriasis, Crohn’s disease
Teratogenic; 6 months contraception after stopping
DMARD - used in moderate to severe RA
Anti-folate (folic acid given NOT on same day to reduce side effects)
Annual flu vaccine
Give treatment booklet
ONCE WEEKLY
Avoid OTC NSAIDs; really excreted drug can increase toxicity

Question 9

Methotrexate symptoms to report

Answer 9

Blood disorders - sore throat bruising, mouth ulcers, susceptible to infections, anaemia
Liver toxicity - nausea, vomiting, abdominal discomfort and dark urine
Respiratory effects - shortness of breath; pulmonary toxicity
Thrombocytopenia - bleed and bruise easily

Question 10

Methotrexate monitoring

Answer 10

FBC, renal and liver function tests repeated every 1-2 weeks until therapy stabilised, should be monitored every 2-3 months
Report all signs of infection esp sore throat

Question 11

Methotrexate interactions

Answer 11

NSAIDs
Aspirin
Any drugs that increases risk nephrotoxicity and myelosuppression

Question 12

Glucosamine

Answer 12

Found in the cartridge
Mixed evidence for use
Natural substance
CI in shellfish allergies
Avoid in pregnancy and warfarin (increases effect)
Not available on NHS as there is no strong evidence
S/e; constipation, diarrhoea, fatigue and GI discomfort

Question 13

Gout

Answer 13

Inflammatory arthritis
High levels of uric acid
Can form needle-like crystals in joint causing pain
Symptoms; sudden severe episodes of pain, tenderness, redness, warmth, swelling
Avoid drugs causing hyperuricaemia; diuretics, ciclosporin, cytotoxics, cancer

Question 14

Acute treatment of gout

Answer 14

High dose NSAIDs (diclofenac and naproxen until attack passes - also consider PPI)
Aspirin NOT used can make gout worse; if already taking for other conditions leave it
Colchicine used if NSAIDs is contraindicated
If colchicine is contraindicated consider corticosteroid injections by specialists

Question 15

Colchicine treatment use

Answer 15

500 mcg 2-4 times a day until symptoms relieved
Maximum 6 mg per course (12 tablets)
Don’t repeat within 3 days
S/e; abdominal pain and diarrhoea
STOP STATIN = increases risk of rhabdomyolysis

Question 16

Long term treatment of gout

Answer 16

Need to allow acute attack to pass first (2-4 weeks after flare up)
ONLY if attack occurs during prophylaxis, continue as normal and treat acute attack separately
Allopurinol 100 mg OD after food
S/e; GI disturbances, discontinue if rash occurs (discontinue and reintroduce)
Decrease dose if taken with mercaptupourine or azathioprine
Alternative febuxostat; s/e serious hypersensitivity reactions SJS, anaphylaxis
Uriosuric drugs; sulfinopyrazone (s/e; urine alkaline = urea crystals)

Question 17

Lifestyle advice for gout

Answer 17

Rest and raise limb
Keep joint cool - apply ice
Drink plenty water; dehydration trigger it
Loose weight if overweight

Question 18

Myasthenia gravis

Answer 18

Rare long term condition
Muscle weakness
Type of neuromuscular disorder
Anti cholinesterase used to inhibit enzyme and prolong action

Question 19

Quinine

Answer 19

Nocturnal leg cramps
Restricted use; sleep regularity disturbed, painful cramps, non-pharmacological not worked
S;e; QT prolongation, convulsion, arrhythmias, toxic in overdose
May take up to 4 months for improvement
Assess every 3 months

Question 20

Baclofen

Answer 20

Used for spasm, chronic severe spasticity
Avoid abrupt withdrawal as it may exacerbate spasticity
Hyperthermia, psychiatric reactions
Gradual reduction at least 1 to 2 weeks
S/e; confusion, constipation, anxiety, drowsiness, muscular

Question 21

Methocarbamol

Answer 21

Short term symptomatic relief of muscle spasm
CI; epilepsy, myasthenia gravis, brain damage
Drowsiness may affect performance of skilled tasks

Question 22

NSAIDs counselling points

Answer 22

Take with or after food
Can worsen symptoms of asthma = bronchospasm
Alcohol increases the risk of GI haemorrhage associated with NSAIDs
Sick day rule; stop when feeling unwell with vomiting and diarrhoea
NSIADs concomitant use with aspirin should be avoided
The lowest effective dose at shortest period of time
Increases risk upper GI events alendronate, anticoagulants, corticosteroids, SSRIs, older patients
Avoid in severe HF or or their co-morbidities
Avoid in pregnancy; 3rd trimester as it can delay labour, pulmonary hypertension in newborn, premature

Question 23

Selective NSAIDs

Answer 23

Less GI effects BUT more cardiovascular risk
Celecoxib

Question 24

Non-selective NSAIDs

Answer 24

More GI risk BUT less cardiovascular risk
Consider PPI
Highest risk; ketoprofen, piroxicam
Low dose; ibuprofen, selective

Question 25

NSAIDs and interactions

Answer 25

Increases risk AKI - ACEi, Ciclosporin, tacrolimus, diuretics
Increase bleeding - warfarin, NOACs, heparins, SSRIs, venlaflaxine
Decreases renal excretion - increases toxicity of methotrexate and lithium
Increased HYPERkalemia risk - potassium sparring diuretics
Increases convulsion risk - quinolones

Question 26

NSAIDs side effects

Answer 26

GI bleeds, discomfort, ulceration,
Hypersensitivity - CI hives, bronchospasm, angioedema
Photosensitivity - topical NSAIDs e.g ketoprofen
Nephrotoxicity - really cleared
Sodium and Fluid retention - caution in HF, renal impairment, hypertention

Question 27

Ottawa rules ankle injury - refer

Answer 27

Inability to bear weight - walk four steps after injury
Bone tenderness alonf posterior edge of the fibula or tip of the lateral malleolus
Bone tenderness along the distal of the posterior edge of the tibia or the medial malleolus

Question 28

Ottawa rules knee injury - refer

Answer 28

Inability to bear weight
55 +
Tenderness at the head of the fibula
Isolated tenderness of the patella
Instability to flex the knee to 90 degrees

Question 29

Questions to ask about joint pain

Answer 29

Is pain in both sides (is it symmetrical )
Any other joint affected
How long
Any recent trauma or injury
Other symptoms; swelling? Stiffness?

Question 30

Sciatica

Answer 30

No benefits for NSAIDs
For long term; consider epidural injections local anaesthetics or corticosteroids