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Competency > MSK (OA, RA, Gout) > Flashcards

MSK (OA, RA, Gout) Flashcards

1
Q

Pathophysiology of gout?

A

over-production of uric acid +/ under-excretion of uric acid -> increase uric acid -> deposit monosodium urate crystals in articular & periarticular tissues -> inflammation & pain

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2
Q

What kind of diet leads to gout?

A

Purine-rich food (guanine & adenine): red meat, seafood

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3
Q

What drugs lead to under-excretion of uric acid?

A
  • diuretics (loop, thiazide)
  • ethambutol
  • pyrazinamide
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4
Q

Symptoms of gout:
- inflammation
- motion
- stiffness
- other characteristics
- onset
- symmetry
- time of occurrence

A
  • inflammation: swelling, red, pain (very bad for hours), warmth
  • motion: restricted
  • stiffness: NA
  • other characteristics: gout tophi
  • onset: rapid
  • symmetry: asymmetrical (usually MTP of big toe)
  • time: night? (lower temp)
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5
Q

Symptoms of OA:
- inflammation
- motion
- stiffness
- other characteristics
- onset
- symmetry
- time occurrence
- pain (precipitating & relieving factors)

A
  • inflammation: swelling, red, pain, warmth
  • motion: restricted
  • stiffness: morning <30min
  • other characteristics: affected by weather, crepitus on movement
  • onset: gradual
  • symmetry: asymmetrical (weight-bearing)
  • time: worse at the end of the day (rarely nocturnal)
  • pain: on movement, relieved by rest
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6
Q

Symptoms of RA:
- inflammation
- motion
- stiffness
- other characteristics
- onset
- symmetry
- time of occurrence
- pain (precipitating & relieving factors)

A
  • inflammation: swelling, red, pain, warmth
  • motion: restricted
  • stiffness: morning >30min
  • other characteristics: fatigue, fever, weight loss, deformities, other systemic sx
  • onset: gradual
  • symmetry: symmetrical
  • time: worse in morning (nocturnal pain)
  • pain: on rest, relieved by movement
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7
Q

Is asymptomatic hyperuricaemia = gout?

A

No

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8
Q

First line for 1st attack of gout?

A
  • colchicine
  • NSAID
  • corticosteroids (PO/intra-articular/IM)
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9
Q

First line for chronic gout (prevent next attack)?

A
  • allopurinol
  • febuxostat
  • probenecid
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10
Q

Diff between crystals of gout and pseudo gout?

A
  • gout: needle negative birefringent crystals
  • pseudo gout: rhomboid positive birefringent crystals
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11
Q

How to determine gout is present?

A

joint aspiration (synovial fluid) -> detect presence of monosodium crystals

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12
Q

What is clinical remission of gout?

A

No flares for ≥1y & no tophi

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13
Q

When to treat acute flares of gout?

A

ASAP (within 24h)

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14
Q

If pt was already on ULT when the acute flare happens, does the pt continue ULT?

A

Yes

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15
Q

Colchicine MOA?

A

Leukocyte motility inhibitor (tubulin disruption)

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16
Q

DDI with colchicine?

A

macrolides, azoles, statin (colchicine is 3A4 substrate)

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17
Q

Nonpharm for gout?

A
  • weight loss if overweight
  • exercise (but rest affected joints during gout attack)
  • avoid smoking
  • healthy diet (low-fat dairy products, veg, water; avoid alcohol, sugary drinks, high-purine food)
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18
Q

Complications of gout (if left untreated)?

A

Tophi, kidney/bladder stones, joint damage

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19
Q

ULT treatment criteria?

A
  • frequent acute gout flares (≥2/year)
  • presence of tophi
  • radiographic damage due to gouty arthritis
  • history of urolithiasis
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20
Q

When to refer to specialist for gout?

A
  • severe / refractory gout (e.g. recurrent flares despite reaching target serum urate levels with ULT)
  • eGFR <30
  • difficulty in achieving management goal with ULT
  • serious adverse effects from ULT
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21
Q

Target urate levels for those with and without tophi?

A

Without: <6 mg/dL (360 µmol/L)
With: <5 mg/dL (300µmol/L)

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22
Q

Does allopurinol or febuxostat have a higher risk of causing CV death?

A

Febuxostat

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23
Q

Dose of allopurinol when initiating and titrating and max dose?

A

Start: 50-100mg/day (start low)
uptitrtte in 50-100mg Q4-8w (go slow)
max: 900mg/day (normal renal function)

24
Q

MOA of allopurinol & febuxostat?

A

xanthine oxidase inhibitor -> inhibit uric acid synthesis

25
Q

MOA of probenecid?

A

uricosuric agent -> increase uric acid excretion

26
Q

SE of allopurinol & febuxostat?

A

SCAR (SJS, TEN, DRESS) in first 3m after therapy initiation
sx: flu-like sx (fever, body aches etc), mouth ulcers / sore throat, red / sore eyes, rash

27
Q

Febuxostat dose?

A

start: 40mg
up to 80mg/day

28
Q

CI for probenecid?

A
  • urolithiasis
  • CrCl <30 (not as effective)
29
Q

Which ULT has risk of haemolytic anaemia in pts with G6PD deficiency?

A

Probenecid

30
Q

What is the risk of using ULT esp during initial period of starting meds?

A

Precipitate acute flares

31
Q

What can be used as prophylaxis against acute flares during initial period of ULT? (include dose & duration)

A
  • Colchicine 0.5-0.6mg OD up to 6m
  • NSAIDs / corticosteroid (if cannot use colchicine)
32
Q

Colchicine SE?

A
  • N/V/D
33
Q

Risk factors for allopurinol-induced SCAR?

A

RASHES
- renal impairment
- agent (concomitant use of therapeutic agents e.g. diuretic)
- starting dose (high)
- HLA-B*58:01
- escalation (rapid increase in dose)
- seniority (old age)

34
Q

Dose of colchicine for acute flares?

A
  • one-off tx with 1mg or 1.2mg loading dose, then one dose of 0.5mg or 0.6mg 1h later
    OR
  • 0.5mg or 0.6mg BD-TDS until acute flare resolves
35
Q

What kind of joints does OA usually affect?

A

Weight-bearing joints

36
Q

1st line for OA and other options for tx?

A

1st line: topical NSAIDs
Others: PO NSAIDs, paracetamol, tramadol, topical capsaicin, IA glucocorticoid injection, duloxetine

37
Q

Nonpharm for OA?

A
  • exercise (strengthening, aerobic, mind-body)
  • weight management
  • physical & occupational therapy
  • surgery if all else fails
38
Q

What is RA?

A

Autoimmune disease, attack articular cartilage & underlying bone

39
Q

Examples of deformities of RA?

A
  • swan neck
  • boutonniere
40
Q

Systemic sx of RA?

A
  • fever
  • fatigue
  • weight loss
  • extra-articular complications (affecting eye, heart, haem, lung, renal, skin, vascular)
41
Q

Lab findings of RA?

A
  • positive rheumatoid factor
  • positive anti-CCP assays
  • increase ESR & CRP
42
Q

Diagnosis of RA?

A

≥4/6 of the following:
- early morning stiffness ≥1h for ≥6w
- swelling of ≥3 joints for ≥6w
- swelling of wrist / MCP/ PIP joints for ≥6w
- rheumatoid nodules
- +ve RF +/ anti-CCP tests
- radiographic changes

43
Q

What is considered remission of RA?

A

≥6m of Boolean 2.0 criteria
- tender joint count ≤1
- swollen joint count ≤1
- CRP ≤ 1mg/dL
- patient global assessment using 10cm VAS ≤2cm

44
Q

Nonpharm for RA?

A
  • psychosocial interventions (e.g. CBT)
  • rest inflamed joints
  • exercise
  • PT/OT
  • weight management
  • diet (decrease inflammation -> fish oil)
45
Q

1st line for RA? Other possible options for tx?

A

1st line: DMARDs
Others: NSAIDs (short-term relief), corticosteroids (low-dose bridging therapy when initiating DMARDs)

46
Q

How long should corticosteroids be used for RA?

A

taper & discontinue within 3m

47
Q

Examples of csDMARDs? Which one is preferred for initial RA tx in DMARD-naive pts (depending on disease activity)?

A
  • hydroxychloroquine
  • sulfasalazine
  • methotrexate
  • leflunomide

Preferred:
- Low disease activity: hydroxychloroquine > sulfasalazine > MTX > leflunomide
- High disease activity: MTX

48
Q

What should be given together with MTX?

A

Folic acid 5mg/week

49
Q

Should steroids be used together with bDMARD/tsDMARD?

A

No

50
Q

If pts with MTX are not at target, what else can be added for RA?

A
  • bDMARD/tsDMARD
  • hydroxychloroquine & sulfasalazine (triple therapy)
51
Q

Rescue therapy for MTX?

A
  • folate (high dose)
  • folinic acid / folinate
52
Q

Examples of bDMARD?

A

Anti-TNF mAbs (infliximab, adalimumab)

53
Q

Examples of tsDMARD?

A

JAK inhibitors (-tinib)

54
Q

What pre-treatment screening is required before starting bDMARD/tsDMARD?

A
  • TB (if have, start tx after completing anti-TB tx)
  • hep B & C
55
Q

What vaccinations are required before starting bDMARD/tsDMARD?

A
  • pneumococcal
  • influenza
  • hep B
  • varicella zoster
56
Q

Can use bDMARD and tsDMARD together?

A

No

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