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Year 2 Pharmacology > MSK Pharmacology > Flashcards

MSK Pharmacology Flashcards

1
Q

Two methods of managing inflammatory arthritis?

A 
Symptom relief:
Paracetamol
Opiate compounds
NSAIDs
Atypical analgesics

Disease modifiers:
DMARDs - methotrexate, sulphasalazine, hydroxychloroquine
Biologics - anti-TNF (rituximab, tocilizumab)

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2
Q

What are pure analgesics?

A

E.g: paracetamol (pure analgesic with little anti-inflammatory action); it is a component of many compound analgesics, like co-codamol

Adverse effects are rare in therapeutic doses but they are very dangerous in overdose

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3
Q

Types of analgesics?

A

Co-codamol
Dihydrocodeine
Tramadol

Add-on drugs:
Amitriptyline
Gabapentin

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4
Q

Steps in pain treatment ladder?

A

Step 1:
Non-opioid (e.g: aspirin, paracetamol, NSAID) +/- adjuvant

Step 2:
Weak opioid for mild to moderate pain, e.g: codeine, +/- non-opioid +/e adjuvant

Step 3:
Strong opioid for moderate to severe pain, e.g: morphine, +/- non-opioid +/- adjuvant

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5
Q

Examples of NSAIDs?

A 
Ibuprofen
Naproxen (first in Tayside)
Diclofenac
Indometacin 
Etodolac
Celecoxib (cox-2 inhibitor)
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6
Q

Indications for NSAID use?

A

Inflammatory arthritis

Mechanical MSK pain

Pleuritic/pericardial chest pain

Other painful conditions

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7
Q

Adverse effects of NSAIDs?

A

Dyspepsia
Oeosphagitis and gastritis
Peptic and small/large bowel ulceration

Renal impairment

Increased risk of CV events (esp. with cox-2 inhibitors)

Fluid retention

Wheeze

Rash

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8
Q

What are Cox-2 inhibitors?

A

NSAIDs which selectively target cyclooxygenase-2, an enzyme responsible for inflammation and pain

Targeting COX-2 selectively reduces the risk of peptic ulceration

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9
Q

Action of DMARDs?

A

Purely anti-inflammatory with no direct analgesic effect; they reduce the rate of joint damage but are SLOW-ACTING (takes weeks to months)

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10
Q

Indications for DMARDs?

A

Active inflammatory disease where the benefit > risk (usually always)

Almost all patient will new onset RA; aim to start a DMARD within 3 months of symptoms onset

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11
Q

Commonly used DMARDs?

A

Methotrexate (1st line)
Sulphasalazine
Leflunomide
Hydroxychloroquine

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12
Q

Steps in DMARD therapy for RA, according to SIGN guideliness?

A
  1. Methotrexate and sulphasalazine are DMARDs of choice
  2. Therapy should be sustained in patient with early RA to control symptoms and signs
  3. Combination DMARD strategy, rather than monotherapy, if patients have an inadequate response, i.e: add another DMARD to the initial

Steroids and NSAIDs are used as bridging therapy, until the DMARD provides relief

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13
Q

How is methotrexate used in RA?

A

Unknown mode of action

1st CHOICE DMARD and can be given orally/subcutaneously; it is often used in combination with another DMARD

It is a folate antagonist, so folic acid supplementation

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14
Q

Conditions in which methotrexate is used?

A

RA, psoriatic arthritic, CTD and vasculitis

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15
Q

Adverse effects of methotrexate?

A

Leucopenia/thrombocytopenia

Hepatitis/cirrhosis (alcohol intake must be limited)

Pneumonitis

Rash/mouth ulcers

Nausea/diarrhoea

Teratogenic (must be stopped in males and females at least 3 months before conception)

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16
Q

Monitoring with methotrexate use?

A

FBC and LFTs regularly

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17
Q

Use of sulphasalazine?

A

Often used in combo with methotrexate in early inflammatory arthritis

18
Q

Adverse effects of sulphasalazine?

A

Nausea

Severe rash and mouth ulcers

Neutropenia

Hepatitis

Reversible oligozoospermia (semen with a low conc. of sperm)

19
Q

Monitoring sulphasalazine use?

A

FBC and LFTs

20
Q

Use of leflunomide?

A

Similar efficacy to methotrexate and similar side effects (also teratogenic)

It has a very long half-life so patients must not become pregnancy for 2 years after stopping

It can be a 2nd line drug, in compe with sulphasalazine, for RA if, e.g: the patient cannot tolerate methotrexate

21
Q

Use of hydroxychloroquine in RA?

A

NO EFFECT on joint damage but used in connective tissue disease, such as SLE, Sjogren’s syndrome and RA (as an add-on therapy)

22
Q

Adverse effects of hydroxychloroquine?

A

Rarely, retinopathy

23
Q

What are biologics?

A

Target specific components of the immune system that are implicated in inflammatory arthritis, e.g: TNF, IL-6, etc

24
Q

Use of biologics?

A

Currently licensed for RA, psoriatic arthritis and ankylosing spondylitis

More effective in combo with DMARDs and are mostly administered via sub-cutaneous injection

25
Q

Examples of anti-TNF drugs?

A

Etanercept, Adalimumab, Certolizumab, Infliximab, Golimumab

Biosimilars: Benepali

26
Q

Conditions to be met before qualifying for biologic prescription?

A

High DAS 28 score (> 5.1)

Must have tried 2 DMARDs, inc. methotrexate

27
Q

Adverse effects of anti-TNF drugs?

A

Risk of infection

REACTIVATION OF LATENT TB (if a patient comes with fever, night sweats, weight loss, etc, be suspicious of this)

Slightly increased risk of skin cancer

Contraindicated in pulmonary fibrosis and heart failure

28
Q

Other biologic agents?

A

Rituximab (B-cell depletor)

Tocilizumab (inhibits IL-6), Ustekinumab (inhibitts IL-12 and 23), Secukinimab (inhibits IL-12 and 23)

Abatacept (blocks full activation of T cells)

29
Q

Summary of the biologics used in different MSK disorders?

A

PICTURE 10

30
Q

Treatment of an acute episode of gout?

A
  1. NSAIDs + PPI
  2. If NSAIDs are contraindicated, Colchicine (commonly causes diarrhoea)
  3. If both of the above are contraindicated, steroids (oral/IM)

These suppress pain and inflammation until the acute flare ends

Also, advise an ice pack

31
Q

Testing in an acute flare of gout?

A

Serum uric acid (may be low during an acute flare, as uric acid precipitates)

32
Q

Drugs used for gout prophylaxis?

A

Started a few weeks after an acute flare, as it can sometimes worse a flare

  1. Allopurinol
  2. If contraindicated, febuxostat
  3. Uricosurics, e.g: probenecid, azapropazone
33
Q

How do urate-lowering drugs, like allopurinol/febuxostat, work?

A

Xanthine oxdiase (converts xanthine to uric acid) inhibitors

34
Q

Adverse effects of allopurinol?

A

Rash (vasculitis) commoner in elderly and in renal impairment, therefore use lower doses

Rarely, irreversible bone marrow aplasia

35
Q

Contraindications with allopurinol?

A

Azathioprine interaction can cause irreversible bone marrow aplasia

36
Q

Adverse effects of febuxostat?

A

Renal impairment

Use in caution in patients with ischaemic heart disease

37
Q

How to decide if gout prophylaxis is required?

A

Follow-up 6 weeks later and measure serum uric acid

If above 360 micromoles/L, or if they have had previous episodes, prescribe

38
Q

Aim of gout prophylaxis?

A

Uric acid < 360 micromoles/L makes it very unlikely that they will have any more episodes

39
Q

Indications for steroid use?

A

CTDs, polymyalgia rheumatica/giant cell arteritis, vasculitis, RA

40
Q

Adverse effects of corticosteroids?

A

Centripetal obesity

Muscle wasting

Skin atrophy

Osteoporosis (lower bone density)

Diabetes

Hypertension

Cataract and glaucoma

Adrenal suppression

Immunosuppression

Avascular necrosis of the femoral head

41
Q

How are steroids used for these conditions?

A

Tend to be given as short, low doses but there are exceptions; consider steroid-sparing agents and osteoporosis prophylaxis

Monitor CV risk factors

Year 2 Pharmacology (7 decks)

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