MSK Flashcards
Arthritis
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
Rheumatoid arthritis
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
Rheumatoid arthritis testing
ESR / CRP elevated
C reactive protein used to differentiate
RhF positive
Osteoarthritis
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
Rheumatoid arthritis drug treatment
DMARDs
Sulfasalazine
Azathioprine
Ciclosporin
Less commonl leflunomide, penicillamine, gold, antimalarials, cytokine modulators
DMARDs
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
Osteoarthritis treatment
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
Methotrexate
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
Methotrexate symptoms to report
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
Methotrexate monitoring
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
Methotrexate interactions
NSAIDs
Aspirin
Any drugs that increases risk nephrotoxicity and myelosuppression
Glucosamine
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
Gout
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
Acute treatment of gout
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
Colchicine treatment use
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
Long term treatment of gout
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)
Lifestyle advice for gout
Rest and raise limb
Keep joint cool - apply ice
Drink plenty water; dehydration trigger it
Loose weight if overweight
Myasthenia gravis
Rare long term condition
Muscle weakness
Type of neuromuscular disorder
Anti cholinesterase used to inhibit enzyme and prolong action
Quinine
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
Baclofen
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
Methocarbamol
Short term symptomatic relief of muscle spasm
CI; epilepsy, myasthenia gravis, brain damage
Drowsiness may affect performance of skilled tasks
NSAIDs counselling points
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
Selective NSAIDs
Less GI effects BUT more cardiovascular risk
Celecoxib
Non-selective NSAIDs
More GI risk BUT less cardiovascular risk
Consider PPI
Highest risk; ketoprofen, piroxicam
Low dose; ibuprofen, selective