MSK

Question 1

If a patient cannot tolerate alendronic acid, what the next line agent offered?

Answer 1

Risedronate.

Question 2

What are the management options for treatment of the acute phase of Gout?

Answer 2

Acute management:

• NSAIDs or colchicine 1st line.
• prednisolone if above contra-indicated (15mg/day).
• intra-articular steroid injection
• if already taking allopurinol - continue this.

Question 3

What are the indication for use of urate-lowering therapy (ULT)?

Answer 3

• British society of rheumatology (BSR) now advocates ULT to all pts after 1st gout attack.
• particularly recommended if:
  a) Tophi
  b) =>2 attacks in 1 year.
  c) renal disease
  d) prophylaxis if on cytotoxics or diuretics.

Question 4

What options are there for the urate-lowering therapy ?

Answer 4

• Allopurinol first line.
• 2nd line if allopurinol not tolerated or inffective - febuxostat.
• in refractory cases, other options are:
  a) uricase
  b) pegloticase - infusion given once every 2 weeks.

Question 5

What test to we use to assess for hypermobility?

Answer 5

Beighton score

- is positive if at least 5/9 in adults or at least 6/9 in children.

Question 6

What are some common features and complications of Ehler-Danlos syndrome?

Answer 6

• elastic, fragile skin
• joint hypermobility - recurrent dislocations
• easy bruising
• aortic regurg, mitral valve prolapse and aortic dissection.
• SAH
• angioid retinal streaks

Question 7

What’s the current guidelines for treatment of RA?

Answer 7

DMARD monotherapy +/- short course bridging prednisolone.

Question 8

How is treatment response in RA monitored?

Answer 8

combination of CRP and disease activity (composite score such as DAS28).

Question 9

a pt taking TNF-alpha inhibitors, what should you do if they get an infection?

Answer 9

if pt taking etanercept who develops an infection needs to stop etanercept until the infection is cleared.

Question 10

How do we assess for osteoporosis?

Answer 10

Management of fragility fractures depends on age:

1. =>75yrs who have had fragility fracture are presumed to have underlying OP, and should be started on 1st line therapy i.e. oral bisphosphonate without need for DEXA.
2. <75 yrs, a DEXA should be arranged. These can then be entered into FRAX assessment to determine fracture risk.

Question 11

Some features of Perthes’ disease.

Answer 11

• typical age 4-8yrs
• due to AVN of femoral head, specifically the femoral epiphysis.
• 5 times more common in boys
• 10% of cases are bilateral.

Question 12

Primary vs secondary Baker’s cysts

Answer 12

• Primary cysts are idiopathic - no comunication between bursa and the knee joint. Not associated with disease of the knee joint and are found most commonly in children.
• Secondary cysts - associated with underlying disease of knee joint (such as OA), tend to have communication between the bursa and the rest of the knee joint. Almost all baker’s cysts in adults are secondary cysts.

Question 13

Which important interactions should be kept in mind when prescribing Allopurinol?

Answer 13

• Azathioprine: allopurinol can lead to high level of Azathioprine metabolite (6 mercaptopurine). So a reduced dose e.g. 25% of allopurinol should be used if combo can’t be avoided.
• Cyclophosphamide - allopurinol reduced renal clearance –> marrow toxicity.
• Theophylline - allopurinol causes increased plasma concentration of theophylline by inhibiting its breakdown.