MSK Tx Flashcards
What should be taken with MTX?
folic acid
When should MTX be stopped prior to conception?
3 mo
MTX SE
GI upset, hair loss, oral ulcers, LFTs abnormality,
Increased risk of
infection,
Pancytopenia, allergic rxn, pneumonitis, renal failure, worsening of rheumatoid nodules
What baseline tests does Hydroxychloroquine ( HCQ) require?
eye exam and follow up to monitor retinal tox
Sulfasalazine monitoring requirements
CBC and CMP 2-4 weeks initially, with stable dose every 3 months
Methotrexate (MTX) monitoring
CBC, CMP with starting and adjusting the dose once stable can do q2mo
Leflunomide CI
pregnant women because of the potential for fetal harm
TNF inhibitor monitoring
CMB, CMP, hep B, C, TB test
get live vacc prior to Rx
TNF inhibitor CI
heart failure
TNF inhibitor SE
Increased risk of infections
TB reactivation
Demyelinating disorder
Autoimmune disorder (positive ANA , lupus like syndrome)
New onset and worsening of heart failure
Rheumatoid Arthritis
Early and aggressive tx is impt
NSAIDs
Steroids to ↓ sx rapidly
Daily calcium 1200 mg and vit D 1000-2000 IU
Must get CBC, EST< CRP, Hep B & C serologies and TB testing prior to meds
DMARDs
Methotrexate *MC (take w/ folic acid and avoid alcohol)
Hydroxychloroquine ( HCQ)- can take while pregnant
Biologic DMARDs
Managt HTN, DM, hypercholesterolemia
Smoking cessation
Spondyloarthritis
SpA
NSAIDs
Sulfasalazine/ Methotrexate for peripheral arthritis only
Biologics
Osteoarthritis
DJD
Mild-mod: Muscle strengthening exercises
Weight loss goal of >7.5% bw
NSAIDS, capsaicin
Mod-Severe: Duloxetine, intraatricular steroid, assisted devices, injection
Joint replacement
Osteosarcome
Pre-op chemo
Surgical resection- limb salvage or amputation
Post-op chemo x 1 yr
Blood work and imaging q3mo x 1 yr then q6mo x 2 yrs
Chest CT q6mo x 2 yrs (check for lung mets)
CBC to see effect on bone marrow and RBC prod
Chondrosarcoma
Surgical resection
Does not respond well to chemo or radiation
Great prognosis if you catch it early
Ewing Sarcoma
Surgery
Radiation
Chemo
70% 5 yr survival if local only 30% if mets
Ganglion Cysts
Surgical- open excision to take out entire capsule, requires post-op immobilization x 7 days
Recurrence is common
Septic Arthritis
Ortho emergency!
Surgical debridement and irrigation
IV abx (7-10 days)
Complications: osteomyelitis (bone infection)
Osteomyelitis
Surgical debridement and irrigation
IV abx (at least 6 wks)
Gonococcal Arthritis
Ceftriaxone 1g IM QD until signs and sx improve
Treat pt and partners emperically for Chlamydia (azithromycin or doxy)
Screen for complement deficiency of recurrent disseminated gonococcal infection
Lyme Arthritis
IM ceftriaxone 21-28 days if early disseminated
Doxycycline 21-28 days
Viral Arthritis
Self-limiting, resolves within 1-2 months
Does not cause destructive arthritis
NSAIDs
Septic Bursitis
IV antibiotics
Surgical debridement of bursa
Acute Gout
Self limiting but treat w/in first 24 hr bc will resolve quicker
Anti-inflam
Colchicine inhibits polymerization of microtubules inhibiting neutrophil chemotaxis
NSAIDs at antiimflam dose
Steroids
Chronic Gout
Lifestylye mod: weight loss, exercise, diet
Low Purine Diet
D/c or Δ meds: thiazide ot loop diuretics, niacin, cyclosporin
Δ to Losartan, CCB or statins due to protective effect
CPPD: Pseudogout
Self limiting
Anti-inflammatories
Colchicine
NSAIDs
Steroids
No medication for chronic management
Osteoporosis
Exercise, fall prevention
Calcium (1200-1500 mg/day)
Vit D (800 IU/day)
Avoid tobacco, limit ETOH
Hip protectors
Biphosphonates
Teriparatide (rhPTH)
Abaloparatide
Denosumab- can use for CKD pts
SERM
Calcitonin- max 6 mo
Bisphosphonates MOA
inhibit bone RESORPTION
Bisphosphonates CI
doNOTuseinpatients with Class IIIb or higher CKD
Teriparatide (rhPTH) MOA
increases bone formation by osteoblasts
Teriparatide (rhPTH) CI
Pagets
Unexplained alk phos elevation
Children and teens with open epiphyses
Pts with prior radiation therapy
Hyperparathyroidism
h/o hypercalcemia
Abaloparatide CI
Paget disease,
Bone metastases
Skeletal malignancies
Unexplained elevation of alkaline phosphatase
Radiation therapy
Open epiphyses
Abaloparatide MOA
Stimulation of osteoblast function and increased bone mass
Denosumab indications
osteoporosis pts w/ CKD
Impingement Syndrome
Rotator Cuff Syndrome or Rotator Cuff Disease
NSAIDs, rest, ice, activity modification
PT: cuff strengthening, stretching,
coordinated motion
Subacromial injection(s): lidocaine (Xylocaine) + methylprednisolone (Solu-Medrol)
Surgery-rare
Rotator Cuff Tears
Partial Tear
<50% NSAIDs, subacromial steroid inj, PT
> 50% → surg
Complete Tear→
Surgery
Biceps Tendinitis
Conservative measures: rest, NSAIDs, and ROM exercises
US guided steroid injections in the bicipital sheath
Surgery for failed conservative approach
Adhesive Capsulitis
“frozen shoulder syndrome”
Conservative therapy- ice, NSAIDs
Steroid injections
PT is very helpful = GS
Surgery if failed
Glenohumeral Osteoarthritis
PT
NSAIDs- caution in elderly, weight risks/benefits
Mod of activities
Steroid inj (generally not done due to delay in labral healing)
Surgery- joint arthroplasty
Lateral Epicondylitis
tennis elbow
Rest and NSAIDs (short term) very successful
PT: US, icing, friction massage
Steroid inj for immediate relief but
no LT benefits
Arthroscopic debridement
(outcomes are no better than conservative measures)
Medial Epicondylitis
golfer’s elbow
Rest, NSAIDs, friction massage, ultrasound, icing
Splinting- don’t want to do LT bc of muscle atrophy
Steroid inj
Activity mod x 1 mo
Surgery: debridement, bone spur shaving, release of flexor muscle
Olecranon Bursitis
Conservative → compression splinting \+/- aspiration \+/- steroid injection
Surgery→ reserved for failure of conservative tx or in the
pt w/ infective bursitis→
debridement/
bursal excision
De Quervain Disease/Tenosynovitis
mommy thumb
Activity modification
Ice
NSAIDs
Thumb spica splint
Injections along tendon sheath
Duuytren’s Contracture
Early in the disease→ adjust work environment (wear appropriate gloves, cushion tape, built-up handles, etc.)
Persistent symptoms →
Intralesional steroid inj
or
Surgical repair (if contracture present)→ open fasciotomy
Polymyositis
Induction- IV steroids then po prednisone 1 mg/kg/day
Maintenance Methotrexate or Imuran
Mycophenolate Mofetil (esp for ILD)
Tacrolumus (esp for ILD)
IVIG
Rituximab
Dermatomyositis
Induction- IV steroids then po prednisone 1 mg/kg/day
Maintenance Methotrexate or Imuran
Mycophenolate Mofetil (esp for ILD)
Tacrolumus (esp for ILD)
IVIG
Rituximab
Inclusion Body Myositis
Low response rate to immunosupp
PT
Rhabdomyolysis
aggressive IV hydration
Polymyalgia Rheumatica
Rapid response to corticosteroids
24 hr imrpovement w/ 10-20 mg po prednisone
Slow taper→ prevent relapse
Steroid-dependent (if relapse when tapering) → methotrexate to facilitate steroid taper
Giant Cell Arteritis
Temporal Arteritis
Induction
Prednisone 60 mg po qd
If visual loss → Solumedrol 1 g IV qd x 3 d
Maintenance
wean prednisone slowly (1 mg/kg/day for 2-4 wks)
15-17 mo tx duration
If flare → add DMARD (methotrexate or tocilizumab)
Fibromyalgia
Pt edu
Analgeisa
Correct sleep disturb
Aerobic exercise*- walking, pool
PT
CBT
Tx of associated d/o
Pharm- SNRI (Duloxetine or Minacipran), ACAs, anticonvulsants (Pregablin), muscle relaxant, ace, NSAIDs
Avoid opiods or narcotics
Most pts will still experience sx despite tx
Cervical Radiculopathy
Conservative mgmt
NSAIDs and tylenol
Muscle relaxers
PT once pain controlled
Many pts get better w/o tx
Refer for surgery → for weakness and persistent sx
Cervical Myelopathy
Conservative management (not ideal)
Surgical Decompression (anterior or posterior)→ goal is to stop from getting worse (won’t cure sx just prevent progression)
Radiculopathy
or
Sciatica
Conservative mgmt
Selective nerve inj
Surgery
Narcotics DON’T do much for neuropathic pain
Acute back pain mgmt
Conservative Management
Activity modification
Bed rest 2-3 days MAX
Low stress aerobic exercise to minimize debility caused by inactivity
Core strengthening, PT
Analgesics
NSAIDs and Acetaminophen
Opiates may be required in the acute phase (not for > 2 weeks)
Muscle relaxers, probably more effective than placebo but have not been shown to be more effective than NSAIDs
Lumbar Spinal Stenosis
Conservative mgmt
Epidural steroid inj
Usually eventually need surgical decompression → elective and usually have sx >1 yr before doing this
Spondylolisthesis
surgery→ fusion
CaudaEquinaSyndrome
Surgical emergency!
Immediate surgical decompression w/ lumbar laminectomy
SLE
Sunscreen, NSAIDS
Glucocorticoids (low dose if not organ threatening)
If organ/life threatening →
High dose glucocorticoids
Immunosuppression
Plaquenil
Scleroderma
Treat contractures w/ PT
Sx benefit from plaquenil
ACE-I for renal crisis
PPI for esophageal dysfn
Cyclophosphamide for ILD
Sildenafil for pulm HTN
Thromboangiitis Obliterans
Vascular surgery
STOP smoking
