MSK and Endocrine Flashcards
Risk factors for osteoporosis
Menopause
age over 60 years
Family Hx
prolonged use of systemic glucocorticoids/anticonvuls
Alcohol/Caffeine/Tobacco *prevention piece
low vitamin D/Calcium (ex. anorexia) - *prevention piece -1200mg/day calcium, 15 mcg/vit D
Physical inactivity *prevention piece - weight bearing
Testosterone/Estrogen defiency
Drugs that decrease bone resorption
Calcium/Vit D
ERT
Estrogen Replacement Moderators
Bisphonates
Calcitonin
Calcium supplements
1,000mg/day in premeno, postmeno 1200-1500
ADR: hypercalcemia
parenteral calcium available for severe systemic hypocalcemia
(calcium gluconate)
Vitamin D agents
Calcitriol, Ergocalciferol
usually rx’ed w/ calcium - inc absorption of Ca+
ADR: severe hypercalcemia - contraindicated in hypercalcemia
Bisphosphonates
most common drug class for osteoporosis
prevention + treatment
structure similar to “pyrophosphates” - natural inhibitor of osteoclast inhibitor
ibandronate, alendronate (fosomax)
poorly absorbed - no food
ADRs: Esophogitis/esophageal ulcer
administer morning - 30 minutes prior to food
take with full glass of water
upright for at least 30 minutes
admin PO or IV - daily, weekly, bi-weekly, monthly - PO ibondronate sodium (boniva) can be administered once a month, IV once/3mo
HRT
Osteoclasts inc as estrogen declines
risk of breast/uterine cx, cholecystitis, MI & CVA
no longer recommended
Raloxifene
SERM - “selective estrogen receptor modifier”
binds to estrogen receptors - produces estrogen-like effect
selective for bones - blocks estrogen receptors in uterus/breast (protective!)
prevention +treatment
not as effective, but safer
ADR: Black Box Warning - DVT & PE
Calcitonin
hormone secreted from the thyroid gland
lowers serum calcium - moves to the bone
less effective than other agents
SQ or nasal spray
Teriparatide (Forteo)
only med that creates bone formation - increases bone deposition by osteoblasts
form of human PTH
ADR:
Arthralgias, back pain, leg cramps
orthostatic hypotension - 4hrs following injection
Black box warning - osteosarcoma (seen only in animals)
daily dosing - SQ only - prefilled pen
Denosumab (Prolia, Xgeva)
Monoclonal antibody that decreases fxn osteoclasts
–> decreased bone resorption
SQ once/month
ADR:
back pain/extremity pain
hypocalcemia
serious infections
dermatologic rxns, dermatitis, eczema
osteonecrosis of the jaw
Rheumatoid Arthritis patho and classes of treatments
progressive inflammatory autoimmune disorder
inflammation of the synoviam, eventual destruction of articular cartilage
symmetrical joint stiffness and pain, most intense in the morning, can have systemic manifestations of inflammation (fever, weakness, weight loss)
nonpharm - pt, heat, exercise (need rest too), joint replacements
Classes:
NSAIDs
Glucocorticoids
DMARDs
NSAIDs
DMARD started early - w/in 3 months of dx
NSAIDs rx strength - relief until DMARD is effective
prostaglandin inhibitors
- reduce vasodilation
- reduce capillary permeability
- reduce fever
- reduce pain
Cox 1
protects the stomach lining
supports renal fxn regulates blood regulates platelet aggregation
Cox 2
triggers inflammation
pain and fever
maintains renal fxn
2nd gen selective cox 2 - celecoxib (celebrex)
ADR: inc risk of MI/CVA - suppression of vasodilation, dec risk of GI ulcer/bleeding, renal impairment (both generations), peripheral edema (sodium/fluid retention)
DMARD - methotrexate
Faster than other DMARDs (3-6wks)
first choice DMARD
chemotherapy drugs - kills fast growing cells
small doses - immunosuppressant - reduces B&T activity
once/week - PO or injection
ADR- hepatotoxic, nephrotoxic, pneumonitis, bone marrow suppression, GI ulceration
monitor liver/kidney fxn + CBC
DMARD - sulfasalazine
Used for decades for IBD
now used for RA
immunosuppressant +anti-inflammatory
can slow the progression of joint deterioration, effects within 1 mo
ADR - many GI effects (enteric coating dec these effects), cross-reactivity/hypersensitivity (sulfa drug), derm effects, bone marrow suppression/hepatotoxicity rare
DMARD - hydroxychloroquine
preferred for pts with mild RA sx
antimalarial
usually given in combo with methotrexate (not effective monotherapy)
ADR: toxicity can –> retinal damage - eye exam prior to trtmt, every 6 mo
DMARD - TNF Blockers
Neutralize TNF which contributes to pathology of RA
mabs except etanercept
given SQ except imfliximab - IV
ADRs: serious systemic infection, fungal - due to potent immunosuppressant
severe allergic rxns
hematologic disorders - neutropenia, thrombocytopenia, aplastic anemia
hepatotoxicity
Classes of drugs for treatment of gout attacks
NSAIDs - indomethacin, naproxen
Glucocorticoids - prednisone (if NSAIDs not tolerated or xindicated)
Colchicine - specific anti-inflammatory
Colchicine
Anti-inflammatory - specific for gout - will not treat other inflamm disorders
Inhibits migration of leukocytes to inflamed site
Used to be 1st line, no longer used as much (NSAIDs more effective) - relieves sx but does not reduce uric acid or promote its excretion
may be used as prophylaxis - reduces frq and int. of flares
80% pts have GI effects - should be d/c if GI sx develop
Drugs for prevention of Gout attacks
Allopurinol
Febuxostat
Probenecid
Allupirinol
Inhibits uric acid formation - final steps of biosynthesis
1st line
used prophylactically in pts w/ hx of gout
education - encourage to increase fluid
Febuxostat
Similar to Allopurinol, lowers uric acid levels
May be used as an alternative
Studies are showing that it is as effective
Probenecid
Increases the rate of uric acid excretion
Inhibits reabsorption of uric acid
Used for chronic gout
Not used for acute attacks - should not be used during the first 2-3 weeks of an acute attack - prolongs the inflammatory process
Baclofen
Spasticity
Prototype Centrally Acting Agent
Acts w/in spinal cord to suppress hyperactive reflexes - may mimick GABA
no direct effect on skeletal muscles (will not dec strength)
Available as tablets, suspensions, intrathecal solutions
ADR: CNS depressant, OD could lead to coma and resp depression, pts should avoid alcohol/other CNS depressants. Abrupt withdrawal of can lead to hallucinations, paranoia, seizures
Dantrolene
Spasticity
Prototype for direct acting - acts directly on skeletal muscle (50% decrease in degree of skeletal contraction without affecting cardiac or smooth)
oral - skeletal muscle relaxant, IV - trtmt malignant hyperthermia
ADR: muscle weakness, hepatotoxicity, drowsiness
4 medications for muscle spacticity
Baclofen, diazepam, tizanidine - CNS
Dantrolene - acts directly on skeletal muscles
Nonpharm treatment for muscle spasms
hot/cold application
hydrotherapy
therapeutic ultrasound, traction
herbal remedies - Kava, black cohosh, castor oil, capsaicin (cayenne)
pharm treatment of muscle spasms
NSAIDs - aspirin, naproxen, ibuprofen
CNS skeletal muscle relaxants - for mod to severe
promote pain relief by relaxing tight muscles, used in combo w/ NSAIDs
cyclobenzaprine (flexeril), carisoprodol, methocarbamol (robaxin), diazepam (valium)
Cyclobenzaprine (flexeril)
Prototype Drug
works in brainstem and reduces tonic motor activity
ineffective in treating spacticity
ADR: CNS deppressant, anticholinergic effects, cardiac rhythm disturbances, serotonin syndrome (if give w/ drugs that inc. serotonin levels -SSRIs)
Somatropin - biosynthetic GH
Stimulates - bone length, muscle mass, organ growth (will not affect brain or eyes)
Doc’d GH deficiency - trtmt should begin early in life, and continue until epiphyseal closure (status assessed annually) or response no longer seen
Has been documented to increase height by as much as 6 inches in GH deficiency, 1-3 inches in normal GH but short stature
admin at night(natural rise in GH release during sleeping hrs)
cannot be given PO - inactivated in GI
very expensive 20-40k/year
ADR: prolonged admin can –> DM - monitor glucose tolerance
neutralizing antibodies may form
height and weight monitored monthly
glucocorticoids can oppose GH
Treatments for Acromegaly
Surgery, Radiation, Medications (not preferred trtmt option - indicated for large tumors or residual tumors)
Somastatin Analog - Ocreotide (sandostatin)
Acromegaly medication
GH inhibiting hormone - these agents mimic suppressant action of somastatin on pituitary - decrease GH release
GH receptor antagonist - Pegvisomant
Acromegaly medication
thought to be the most effective drug
Pharm mgmt of DI
Vasopressin - identical to natural ADH
Desmopressin (DDAVP) (preferred)
Vasopressin
Duration 2-8 hours (DDAVP longer)
IM or SQ
potent vasoconstrictor - used to raise BP, cardiac resuscitation (not first line)
ADR: water intoxication - (HA, N/V, confusion, edema) ed - decrease water intake, risk inc w/ renal dysfxn
excessive vasoconstriction - angina, MI, gangrene in periphery
xid in patients with CAD
Desmopressin Acetate (DDAVP)
duration 8-20 hrs
available as nasal spray (also PO, SQ, IV)
agent of choice because less intense of vasoconstrictor
can be used (low dose) for nocturia -enuresis (bed wetting)
Levothyroxine Sodium - synthetic T4
Narrow therapeutic range - monitor serum levels
Must be taken on an empty stomach (food red. absorption)
Care with cardiac/htn pts - increase in O2 demand, may cause angina
Takes about 1 month to reach therapeutic levels (1/2 life is 7 days, takes 4 half-lives to reach therapeutic levels)
ADR: w/ appropriate dosing - minimal. Thyrotoxicosis - acute OD - tachy, angina, tremors, nervousness, hyperthermia, insomnia, sweating
education s/s of hyperthyroidism
myxedema coma
Treatments for hyperthyroidism
thyroidectomy, radioactive iodine therapy, antithyroid drugs
any of these can lead to hypothyroidism
Methimazole
Propylthiouracil (PTU)
Propanolol
Drugs used for hyperthyroidism
m - First line/prototype
do not destroy existing reserves of TH, may take 3-12 weeks to stabilize TH level
may be used long-term or in preparation for subtotal thyroidectomy
**use in pregnancy - PTU safer **- decreased placental passage
Hypothyroidism
Agranulocytosis - should be d/c’ed. Sore throat, fever early indicators, monitor WBC closely, may be treated with filgrastim
bblkr for sx
treatments of Cushing Syndrome
Removal of underlying cause (tumors)
Adrenalectomy
d/c GCs (gradually)
medication that suppresses adrenal release of corticosteroids - not first choice treatment for CS
Addisons
adrenal insufficiency - inadequate glucocorticoid and mineralcorticoid
most often autoimmune
requires lifelong replacement therapy with corticosteroids
weight loss?
hyponatremia/hyperkalemia
Hydrocortisone
treatment of addison’s
Synthetic steroid
Drug of choice
contains both a GC and a MC
admin PO for chronic, IV for acute adrenal insufficiency
increase dose during times of physiologic stress
never stop abruptly
Fludrocortisone
Mineralcorticoid agent
for sodium loss/hypotension d/t adrenal insufficiency
promotes Na retention/K excretion
ADR: edema, fluid overload
Dexamethasone
(other glucocorticoid agents) treats inflammation as a result of cerebral edema post neuro surgery
treats allergic rxns
Prednisone
(other glucocorticoid agents)
inexpensive, frequently prescribed
ADRs corticosteroids
when given as replacement, ADRs minimal - dose required is small
when given for non-endocrine disorders, required dose is higher, more side effects - “cushing’s syndrome”
Acute Adrenocortical Insufficiency
Results when GCs abruptly withdrawn from pt on long-term GC therapy
Sx: N/V, lethargy, confusion, coma, fluid volume deficit, hypotension
