MSK Flashcards
Do you treat asymptomatic hyperuricemia?
Not an indication for urate lowering therapy if they are asymptomatic.
This phase usually ends with the first attack or gouty arthritis, typically after 20 years of sustained hyperurcemia
Presumptive diagnosis of gout flare ?
Definitive diagnosis of gout flare ?
what causes gout?
Presumptive:
Monoarthritis
Hyperuricemia (>360 in females and >420 in males)
Dramatic response to colchicine
Definitive:
Identification of intracellular monosodium urate crystals in synovial joints
Causes: 3D’s
Drugs: ACE/ARB, ASA low dose, chemo, cyclosporine, diuretics (tzd, loop), ethambutol, lead, levodopa, niacin, ritonavir, tacrolimus,
Diseases: malignancies, CKD, HTN, obesity, hyperglycemia, hyperlipidemia, surgery/trauma
Diet: purine rich foods ex. alcohol, fish, red meat
Nonpharm for gout flare
Ice topically (adjunct to pharm)
Pharm for gout flare
first line:
-NSAIDS (can protect gastric lining with PPI)
-Colchicine 1.2 mg initially, then 0.6 mg 1 h later for total of 1.8mg
-oral corticosteroids (Prednisone 0.5 mg/kg PO) -> only appropriate if single joint/ not suitable for polyarticular
CI= blood dyscrasia, solid organ transplant
Precautions: decreased renal function
combo therapy is appropriate for severe symptoms
Ex. Colchicine +/- NSAID or steroid
colchicine needs to be giving within 24hours of symptom onset
not recommended if >36hrs since onset
Gout prophylaxis/ maintenance nonpharm and when do you initiate treatment
treat:
-if recurrent attacks (>2 attacks/yr)
-levels >800
2nd attack within 6-12 months of first is often
-subsequent attacks are less severe but more frequent and often polyarticular
- Assess diet, lifestyle
- Assess comorbid conditions and intake of drugs that are associated with this.
- Clear relationship with obesity (BMI >30) and gout
-encourage exercise, gout, smoking cessation, and to remain well hydrated - Limit purine intake
-beef, lamb, pork, seafood (sardines/ shellfish)
-sweetbreads, liver, kidney - limit high fructose corn syrup
- Limit alcohol
-<2/day = men - wt loss program
Gout prophylaxis/ maintenance pharm
treat:
-if recurrent attacks (>2 attacks/yr)
-levels >800
2nd attack within 6-12 months of first is often
-subsequent attacks are less severe but more frequent and often polyarticular
> 2 attacks/annually
evidence of radiograph tophi
1 previous flare, but others infrequent
comorbid CKD
serum urate >535
urolithiasis
Xanthine oxidase inhibitors:
FIRST LINE:
#1 allopurinol
start 100 mg daily PO, titrate q2 weeks to reach target
Goal: 300-800 mg
Check urate at 6 months
-start during flare may be safe but waiting
SECOND LINE= Febuxostat 40mg OD
(only if failed allopurinol// this increases your CVD risk)
THIRD LINE (uricosurics)
-Probenacid (only available through Health Canadas Special Access Program
CI- pt with elevated urine uric acid levels
To note: ULT should be started during gout flare rather than after it resolves
-when starting ULT may result in increased incidence of gout flares, minimize a/e by using low dose NSAID or colchicine while titrating/adjusting allopurinol (~usually 3-6 months)
TARGET: <360 sUA
<300 sUA if tophi, chronic gout pain, flares at <360.
What is serum urate target for uratt lowering therapy
minimum serum target <360
if severe min target <300 (w/ tophaceous gout)
Once urate crystals are dissolved, maintenace target is <360 to avoid developing new tophi
When do you refer for gout?
when:
-unclear cause of hyperuricemia
-unable to reach target urate levels
-persistent symptoms of gout
-multiple or serious a/e from pharm ULT
Side effect of allopurinol
skin rash, GI upset, hepatotoxicity, fever, severe hypersensitivity syndrome, xanthine stones
May cause allopurinol hypersensitivity syndrome (Steven Johnson, toxic epidermal necrolysis, exfoliative dermatitis)
Drugs, disease and diet associated with gout
Causes: 3D’s
Drugs: ACE/ARB, ASA low dose, chemo, cyclosporine, diuretics (tzd, loop), ethambutol, lead, levodopa, niacin, ritonavir, tacrolimus,
Diseases: malignancies, CKD, HTN, obesity, hyperglycemia, hyperlipidemia, surgery/trauma
Diet: purine rich foods ex. alcohol, fish, red meat
What is #1 management for chronic tophaceous gout?
prevention
-correction of hyperuricemia
-aim of therapy are to control pain and inflammation, typically NSAID and to decrease serum uric acid levels (alloporinol)
-after several years of therapy. resorption of urate deposits will eventually lead to disappearance of tophi
what is the first thing to do when you have a gout diagnosis prior to nonpharm/ pharm?
assess renal function, cardiovascular status
treat any associated conditions (HTN)
eliminate nonessential meds that contribute to gout
patient education on lifestyle changes
What are the red flags you want to rule out with neck pain
What are yellow flags?
NIFTI - Red flags
N-neuro
I-infection
F-fracture
T-tumor
I-inflammatory (RA. RA. temporal arteritis)
Yellow flags: -> strong prediction of chronicity
-self reported pain as high intensity
-catastrophizing pain as disabling
-depression, anxiety or signs of PTSD
-passive coping skills
-avoidance of movement
-history of previous MSK pain
classify neck pain through WAD scores
WAD I = neck pain, stiffness or tenderness but no physical limitation
WAD 2= pain, tenderness, reduced range
WAD 3= pain, neurologic signs, sensory or motor, reflex changes w/o fracture/ instability
WAD 4= fracture or dislocation
If Neurologic symptoms -> refer to C-Spine rules for radiography guidance
Acute phase neck pain 1-30 days non pharm and pharm
nonpharm:
-WAD IV-> surgery
-WAD I-III: reassure, counsel to resume normal activity asap. Avoid immobilization or passive therapy except in case of acute radiculopathy
Collars delay recover
-some evidence that return to work may solidify gains made in therapy
-stretching, strenghtening exercises
-if no progress in first month -> consider psychosocial barriers or complications
-active exercises with psychosocial interventions (accelerates return to work)
Pharm:
NSAIDS > Tylenol in first month
+/i
Muscle relaxant (cyclobenzaprine, baclofen, tizanidine)
Second line
Tramadol or codeine
subacute neck pain 4-12 weeks nonpharm and pharm
nonpharm:
-exercise/ stretching #1
-chiropractor/ physio
-massage
-CBT
-acupuncture (weak)
Pharm:
weak evidence to support NSAID
if c/o pain in more than 1 area:
-Muscle relaxant (cyclobenzaprine, baclofen, tizanidine, orphenadrine) ,
-TCA (Amitryptilline)
-GABA (gabapentin, pregabalin)
-Tramadol maybe effective
if pain ++ severe and not responsive to other measures:
-opioids/ low dose for 3-5 days then r/a
Can do trigger point injections with lidocaine and stretching exercises - has some evidence here.
by 3 months, if return to work has not happened. increase risk for chronic pain. -> should refer to multidisciplinary rehab
neck pain chronic >6 mo nonpharm/pharm
nonpharm
-exercise can improve pain/function
-multidisiciplinary team for pain management
pharm:
-muscle relaxant, GABA derivitatives, tramadol may be effective
-opioids (optimize all nonopioids first)
=same treatment at subacute pain
trigger point may be benefiical
Chronic fatigue syndrome nonpharm
post exertional malaise
unrefreshing sleep
impaired cognitive function
pain and orthostatic intolerance
all labs normal
>6 months
-healthy balanced diet
-if orthostatic hypotension -> needs adequate salt, fluid,
-if sleep apnea -> sleep study
-if restless leg -> sleep study
-if orthstatic intolerance -> salt, fluid intake, compression stockings, wlevate legs when sitting -> refer to cardiology
-activity pacing (divide activities into small manageable tasks by rest breaks)
-graded exercise therapy (walking, swimming, cycling, dancing have a positive effect on sleep, physical function
-CBT -> inconsistent findings
Chronic fatigue syndrome pharm
no treatment exists
antidepressants
-TCA (may worsen ortho hypotension) -> choose smaller dose
Can trial a short term trial of antihistamine or prescription of hypnotic at smallest dose possible
chronic fatigue syndrome and pregnancy mainstay
nonpharm approaches, if co-existing depression -assess risk/benefits
fibromyalgia nonpharm
Diagnosis:
-Generalized pain in 4-5 regions
-symptoms present min 3 months
-WPI >7 and SSS >5 or WPI 4-6 with SSS 9
-must r/o other causes
etiology unclear, associated with trauma, adverse life event, impaired mood and anxiety, IBS, irritable mood anxiety, IBS, irritable bladder, cold intolerance, paresthesia
nonpharm:
-pt education (arthritis society- self manament program can help relieve pain)
-individualize management strategies (pt recognize role of various social, psychosocial and environmental factors in exacerbation of aggravated pain. in hopes to decrease pain intensity)
-continue aerobic exercise, sleep hygiene, stress management
-CBT **
-use cold/heat for pain reduction
-electroacupuncture> acupuncture
-specified identification of sexual, physical, emotional abuse, PTSD is an important part of treatment
Fibromyalgia pharm
there is a lack of strong data to support meds
antidepressants:
pain and sleep
1. Amitriptylline at HS (good starting point) #1 ->sleep + pain
5 mg then increase Q2 weeks to 50 mg
if depressed
2. Duloxetine
-if has depression/ also good (helps with sleep and pain)
- SSRI
some evidence of fluoxetine + amitryptilline (more effective together than alone?)
pain only
GABAPINOIDS
1. Gabapentin start at 100 mg HS (up to 1200-2400 mg/day) -> pain
2. Pregabalin start at 300-450 mg ** higher than 450 not beneficial for fibro and >150 also not helpful
OTHERS
Muscle relaxant/ cyclobenzaprine 10mg/ can help with sleep
tramadol/ reported to be helpful (consider if everything fails)
TPI also possible
Management of fibro in pregnancy
1 nonpharm (pain control, stress management, energy conservation)
if nonpharm insufficient
-tylenol
-NSAID (only first trimester)
SSRI/SNRI = increase risk of NAS
Amitryptilline= relatively safe ish
dont use gabapinoids or tramadol
nonpharm for restless legs
typically only effective for mild cases, moderate-severe need pharm alternatives
-engage in mental alertness activities (cards, puzzles) to reduce symptoms in boredom
-abstain from alcohol, caffeine, nicotine
-take hot baths
-stretch and exercise moderately.
-yoga might help, massage might help
-discontinue meds that contribute
antidepressant- mirtazapine
antiemetics- metoclopramide
antiepileptics- topiramate
antihistamines- diphenhydramine
antipsychotics- seroquel, zydis, clozapine
-minimize aggravating factors such as sleep deprivation
-if RLS and varicose veins; consider sclerotherapy to improve RLS
Pharm for restless less syndrome for intermittent symptoms
What blood test should you check before starting a medication?
Start lowest dose and should be administered 1-2 hours prior to bed
** should check iron (most are iron deficient
Intermittent RLS (<2/week) :
~intermittent use of:
first line
1. Levodopa prep
-increased risk of rebound
others
2. benzodiazipines
-not improve core symptoms but improves sleep
- low potency opioids (only if refractory to other treatments)
-strong sedative effect may be responsible for effectiveness
-low potency like codeine are best options
Pharm options for persistent symptoms min 2/ week of RLS
FIRST LINE (esp if symptoms severe, excessive wt, comorbid depression, cognitive impairment or increase risk of falling)
-> Dopamine agonist
-Pramipexole
-Ropinirole
(bromocriptine, rotigotine/ also but others have better a.e profile)
SE= nausea, sedation, lightheadness
** increased risk of developing high risk behaviors like pathological gambling, hypersexuality // need to taper
SECOND LINE (consider first if severe sleep disturbances. comorbid insomnia, anxiety, painful RLS, hx of compulsive behaviors or anxiety)
-> gaba deriviatives
-gabapentin
-pregabalin
management of restless leg in pregnancy and breastfeeding
** often happens in pregnancy/ educate pt about self limiting nature of symptoms in pregnancy **
nonpharm is maintay #1 for both pregnancy and breastfeeding
must r/o iron deficiency
what do you treat in refractory cases of restlessleg syndrome that is resistant to other treatments
Steps:
1. consider combining agents from different drug classes (dopamine agonist, Gaba deriviatives, benzo, low or high potency opioids)
2. if continues to be refractory and resistant to treatment -> high potency opioids (oxycodone or methadone)
muscle cramps, typically associated with lytes disturbances, muscle fatigue, increase excitatory and inhibitory input to motor neurons, heat/cold, hormones, liver disease, meds etc.
what are nonpharm options?
Nonpharm is mainstay #1
-reassure pt benign nature of cramps
-most can be relieved with acute static stretching
-hot pack or hot bath can help relieve cramps
-icing can be used (no study on effectiveness)
what are pharm options for muscle cramps
no med clearly beneficial
magnesium has mixed results
small benefit with dilitazem, vitamin B complex
