MSK Health Flashcards
Frequency of FBC, U+Es and LFTs monitoring in patients on methotrexate?
Every 1-2 weeks until therapy stabilised, then 2-3 monthly.
Name of criteria used to make clinical diagnosis of complex regional pain syndrome?
Budapest criteria
If a patient with RA is affected by lung fibrosis which area of the lungs would you expect to be affected?
lower lobes
Drugs that can raise plasma urate levels?
diuretics e.g. BFM ACE-Is beta blockers tacrolimus ciclosporin ritonavir pyrizinamide
Treatment of acute gout attack if poor renal function?
PO colchicine-note can be taken for up to 1 week to relieve sx
warn patients about diarrhoea
if normal eGFR could offer NSAID 1st line at max dose and continue for 1-2days after acute attack has resolved
Recommended follow up after acute gout attack?
R/v in 4-6 weeks and:
- check serum urate (optimum time to measure is 2 weeks after acute attack has resolved)
- measure BP
- bloods for HbA1c and lipids and U+Es
- identify and manage DM, HTN, hyperlipidaemia or renal impairment, assess overall CVS risk
- advise smoking cessation, reducing alcohol, weight, diet, exercise
- consider advance px for future gout attacks
- discuss urate lowering therapy
When should allopurinol be considered to start for pt with acute gout?
after 1st attack has resolved, can be considered if attacks so frequent this is not possible
Febuxostat=alternative, ensure LFTs checked before starting
Starting dose of allopurinol for gout?
100mg daily, titrate upwards by 100mg every 4 weeks until serum urate less than 300 micromol/L
also check U+Es every 4 weeks whilst uptitrating
once serum urate in range check levels and U+Es annually
max dose 900mg/day
When can the dose of urate lowering treatment in gout be reduced?
after some years of tx, once serum uric acid below 300 and acute attacks stopped and tophi resolved, can consider reducing to aim serum urate between 300 and 360
For which groups of patients is Vit D supplementation advised?
adults >65yrs
pregnant and breastfeeding women (10mcg/day)
those at risk due to less sun exposure
children aged 6mnths-5yrs (not if on >500mls of formula milk)
How long should women avoid pregnancy for after stopping MTX?
at least 6 months
similarly men should use contraception for at least 6 months post stopping MTX
Sx of meralgia paraesthetica?
paraesthesia over lateral aspect of thigh, caused by entrapment of the lateral femoral cutaneous nerve
If suspect new dx of RA in primary care when should a GP refer and by when should the dx be made in secondary care?
GP referral within 3 working days of presentation and specialist assessment to confirm dx within 3 weeks of referral.
GP to r/f within 3 working days if any of the below present:
-small joints of hands or feet affected
->1 joint affected
-delay of 3 months or more from initial sx to GP presentation.
Initial management of suspected RA in primary care?
Consider NSAID with PPI cover at lowest effective dose for shortest possible time before rheumatology can see patient.
Definition of treat to target in management of RA?
Aim to achieve a target of remission or low disease activity if remission cannot be achieved. DAS-28 >5.1 =high disease activity 3.2-5.1= moderate disease activity 2.6-3.1= low disease activity <2.6= disease remission
As per NICE when should patients with new diagnosis of RA start a DMARD?
Should start conventional DMARD monotherapy e.g. MTX, leflunomide, sulfasalazine, within 6 weeks of referral, with monthly monitoring until treatment target met.
Duration of disabling fatigue for diagnosis of chronic fatigue syndrome/ME?
6 months
If uptitrating allopurinol for gout management and patient develops acute attack how should they be managed?
continue urate lowering therapy at current dose and treat gout attack separately (NSAID or colchicine)
How should people aged <40years with major risk factors for osteoporosis have their risk of fragility fracture assessed?
with a DEXA scan to measure bone mineral density
Max dose of allopurinol in renal impairment?
100mg daily
Main symptom of iliotibial band syndrome?
lateral knee pain during exercise and particularly when running downhill
Indication for steroid injections for De Quervain’s tenosynovitis?
if persistent pain and swelling despite use of a splint and NSAIDs
Recommended Pred dose in GP if pt has suspected GCA with visual sx?
60mg PO pred or IV methylpred 1g daily for 3/7
When can OA be diagnosed clinically without further investigation?
if patient over 45 years of age, activity related joint pain and morning stiffness lasting no longer than 30mins
When should patients NOT have their fracture risk assessed with a 10 year fragility fracture risk score before a DEXA?
- if under age of 40 and has major risk factor for fragility fracture
- if over the age of 50 with fragility fractures
- if has vertebral or hip fracture-consider starting treatment without DEXA if DEXA impractical or inappropriate
NICE preferred fragility fracture risk calculator?
QFracture
alternative-FRAX
What is a fragility fracture?
Fracture resulting from a fall from standing height or less, most common locations=wrist, hip and vertebrae
note vertebral fractures may occur spontaneously or as a result of routine activities
Drugs which increase risk of osteoporosis?
Steroids SSRIs PPIs anti epileptics e.g. carbamazepine pioglitazone aromatase inhibitors e.g. letrozole GnRH agonists e.g. goserelin
Who should be assessed for risk of fragility fracture?
- All women aged 65 and over.
- All men aged 75 and over.
- All women aged 50-64 and men 50-74 with a risk factor e.g. smoking/alcohol >14U/week/low BMI/falls hx/PO steroids/previous fragility fracture (DEXA)/secondary cause of OP
- Under age of 50 and either current/frequent use of PO steroids/previous fragility fracture/untreated premature menopause
- Under age of 40 and either previous fragility fracture of spine/hip/prox humerus/forearm/multiple fragility fractures/current or recent use of high dose oral steroids 7.5mg pred daily for 3 months or more.
What 10 year fracture risk following use of a risk assessment tool is the threshold for referral for a DEXA?
10% (high risk)
What risk factor does Qfracture include that FRAX does not?
hx of falls
however, FRAX can incorporate data on BMD if pt has already had a DEXA scan
What tool can be used by GPs to screen patients with back pain in order to categorise them into risk of having a poor outcome?
The Keele STarT back screening tool
Who should be offered a combined physical and psychological programme if persistent low back pain +/- sciatica?
significant psychosocial obstacles to recovery or previous treatments have not been effective
1st line pharmacological management of low back pain?
oral NSAIDs-taken at lowest effective dose for shortest possible time, plus offer gastroprotection
if CI, not tolerated or ineffective, consider a weak opioid +/- paracetamol to manage acute low back pain
if muscle spasm consider short course of BZD e.g. diazepam 2mg up to TDS for up to 5 days
Which other factors should prompt a referral to Rheumatology for a patient with low back pain for more than 3 months and who was aged under 45 when it started?
Refer for spondyloarthritis assessment if 4 or more of these are present: onset below age of 35 pain waking pt up in 2nd half of night buttock pain improvement with movement improvement within 48hr of taking NSAIDs 1st degree relative with spondyloarthritis current/past arthritis current/past enthesitis current/past psoraisis
if 3 are present perform HLA-B27 test-+ve-refer
if clinical suspicion remains but doesn’t meet criteria advise to present again if develops further sx/RFs
When should switching NSAIDs be considered in managing AS?
if NSAID taken at maximum tolerated dose for 2-4 weeks dose not provide adequate pain relief
Clozapine monitoring requirements?
- weekly FBC for 1st 18 weeks, then every 2 weeks up to 1st year, then monthly.
- blood lipids and weight every 3 months for the 1st year and then yearly (other antipsychotics these should be measured at baseline, 3 months and then annually)
- fasting blood glucose at baseline, after 1 month then every 4-6 months.
patient, prescriber and supplying pharmacist must be registered with appropriate patient monitoring service.
Which patients should have bisphosphonate therapy continued without reassessment of risk?
over 75 years of age
previous hip/vertebral fracture
low trauma fracture whilst on therapy
continuing on steroids
Azathioprine blood monitoring?
FBC and LFTs before treatment
weekly FBC in 1st 4 weeks of treatment, then at least every 3 months
Sulfasalazine blood monitoring?
FBC and LFTs monthly for first 3 months, U+Es before starting, at 3 months and then annually
risk of crystalluria in moderate renal impairment
Causes of drug induced lupus?
hydralazine losartan sulfasalazine isoniazid anti epileptics minocycline chlorpromazine
1st line analgesia for frozen shoulder?
regular paracetamol
if this isn’t working, consider an PO NSAID or codeine
physiotherapy should be started as early in the course as possible for frozen shoulder-pain initially then global stiffness before resolution, should have 6/52 of physio-can be continued for a further 6/52 if improvement
can consider intra-articular steroid injection if sx not improving with conservative measures, NOT if pt in stiffness phase
if person has had pain and/or stiffness for up to 3 months consider r/f to secondary care
X-rays for shoulder pain in primary care?
- hx of trauma
- not improving with conservative management or after 4 weeks
- red flags
- severe pain
- movement significantly restricted
- arthritis suspected
