MSR Pharm Cases

Question 1

Your patient has RA. What is your first line DOC?

Answer 1

Methotrexate (Rheumatrix); one pill weekly

Question 2

When prescribing methotrexate, what must you also prescribe?

Answer 2

Folic Acid (5mg weekly)

Question 3

What are the special instructions for Rxing methotrexate and folic acid together?

Answer 3

Folic acid must not be taken on the same day as methotrexate; take it the day after.

Question 4

How long does it take for methotrexate to respond initially and respond fully?

Answer 4

initially - 3-4 weeks; fully - 3-6 months

Question 5

What is methotrexate’s PG category?

Answer 5

X

Question 6

What is the one thing you should definitely be sure to monitor when Rxing methotrexate?

Answer 6

CXR - both before and after treatment (side effect of pulmonary fibrosis)

Question 7

What can you use as a “bridge therapy” while waiting for any RA DMARD to kick in?

Answer 7

Non-steroidals (e.g. ibuprofen) unless contraindicated. If contraindicated, can put on short-term (one month) steroid (prednisone) use.

Question 8

Your RA patient is unresponsive to methotrexate. What is your next line of therapy?

Answer 8

Add a non-biologic DMARD to therapy. (In our class example, we prescribed Etanercept [Enbrel] because the pt had CKD and COPD)

Question 9

Which drug would you use for a patient who is trying to manage RA?

Answer 9

Sulfasalazine (Azulfidine) unless sulfa allergy

Question 10

Are you going to crush this exam?

Answer 10

You’re damn right!

Question 11

What is the major side effect that we must monitor with hydroxychloroquine (Plaquinil)?

Answer 11

It is bound in melanin-containing tissues like the eyes. Must get ophthmology f/u every 6-12 months. Recommended eye exams every 4-6 weeks.

Question 12

Your pt. is on Etanercept (Enbrel) and presents with a raging fever and joint problems. What could be going on, and what should you do?

Answer 12

She probably has an infection. DMARDS are C/I for people with infections, so you need to stop the DMARD. Biologic DMARDS are known to reactivate sepsis, hepatitis, and lymphoma, so screen for these conditions.

Question 13

An elderly woman with glaucoma has chronic rhinorrhea. What is it and how to you treat?

Answer 13

Woahhhh let’s take it back to summer! Vasomotor rhinorrhea - treat with cromolyn sodium because it’s the only NS not C/I for glaucoma.

Question 14

Pt. is having first episode of acute gout. How do you treat?

Answer 14

NSAIDs around the clock for about a week.

Question 15

Your patient has a stomach ulcer and cannot be put on an NSAID for his first episode of gout. What is your next step?

Answer 15

Colchicine

Question 16

What side effect can your patient expect to see with colchicine?

Answer 16

Abdominal pain/diarrhea (80%)

Question 17

Your patient has had 3 episodes of gout in the last year and is sick of it. What should you do for him?

Answer 17

Put him on a prophylactic med for gout - allopurinol (Zyloprim)

Question 18

What drugs predispose you to gout?

Answer 18

Thiazide diuretics, HCTZ, aspirin, niacin - all increase uric acid levels

Question 19

If you have kidney stones, which gout medication are you not indicated to use? Why?

Answer 19

The uricosurics like Probenecid (Benemid). This blocks proximal convoluted tubule reabsorption of uric acid, thus increasing risk for kidney stones.

Question 20

Your patient is currently on Lisinopril (an ace-inhibitor). He is having recurring episodes of gout, so you want to prescribe him allopurinol. What do you need to be aware of?

Answer 20

Allergic reaction with these 2 meds may occur. Changing his HTN med alone may decrease his uric acid level.

Question 21

Your patient has arthralgias. Sure, you COULD prescribe an NSAID, but what OTC medication is just as effective?

Answer 21

OTC oral analgesics

Question 22

Your patient has OA and frequent GI bleeds. What can you prescribe her for her OA?

Answer 22

NOT NSAIDS. Rx acetaminophen instead. If that doesn’t work, try Tramadol If you MUST rx an nsaid, then Celebrex has a lower risk of GI bleeds

Question 23

If you prescribe an NSAID, how long can you expect for anti-inflammatory relief?

Answer 23

2-3 weeks

Question 24

What lifestyle modifications can you make to reduce your chances of getting gout?

Answer 24

Avoid alcohol, purine-rich foods like red meat

Question 25

So allopurinol is a fiesty little drug, and it also interacts with ampicillin/amoxicillin. In what way?

Answer 25

Rash may develop

Question 26

Your patient was doing yardwork and got severe pain in his lower back. No other symptoms. What do you prescribe?

Answer 26

He has a muscle spasm. Give him Cyclobenzaprine (Flexeril)

Question 27

What is a side effect that you should be sure to tell your patient about with cyclobenzaprine (Flexeril)?

Answer 27

Drowsiness/dizziness and CNS depression

Question 28

Your patient has a 3-month old daughter and was prescribed cyclobenzaprine (flexeril) for muscle spasms. What is a possible problem here that needs to be discussed?

Answer 28

Caution with nursing!!

Question 29

Your patient has MS and wants to control her muscle spasms. What do you prescribe?

Answer 29

Baclofen (Lioresal)

Question 30

What should you definitely caution your patient about when starting them on Baclofen (Lioresal)?

Answer 30

It is a black box warning, and should not be stopped abruptly! Make sure you taper them off.

Question 31

Random question, but how are you going to treat a patient who has polyarteritis nodosa?

Answer 31

HD Prednisone and cyclophosphamides.

Question 32

Patient has alopecia, anorexia, fatigue, and a “butterfly rash” over her face. She is coming to you today for her joint pain. DOC?

Answer 32

She has SLE

First check current medications.

DOC = hydroxychloroquine (Plaquinil)

Question 33

How long does it take for hydroxychloroquine (plaquinil) to take effect?

What can you do in the meantime?

Answer 33

3-6 months

Can co-rx prednisone (start HD and taper down)

Question 34

Your patient has a dry mouth and can’t chew or swallow her food. DOC?

Answer 34

She has Sjogren’s.

DOC: pilocarpine

Question 35

What type of drug would you want to use for Raynaud’s phenomenon?

Answer 35

Calcium channel blockers

Question 36

You suspect that your patient has CREST syndrome. What is the BIG thing that you should do here?

Answer 36

Refer to rheum!

Question 37

If your patient has Raynaud’s, what are some lifestyle modifications that could reduce symptoms?

Answer 37

Quit smoking, decrease stress/anxiety, wear gloves in winter

Avoid triggers, avoid vasoconstrictor meds (like decongestants)

Question 38

Your patient has pseudogout. How do you treat?

Answer 38

The same way that you would gout!

Question 39

Sooooo… How do I treat gout again?

Answer 39

1st line: NSAIDs

If NSAIDs are C/I, use colchicine

Use allopurinol for gout prophylaxis

Can also use probenicid (benemid) or febuxostat (uloric)

Question 40

What is the MOA of Allopurinol (zyloprim) vs. probenicid (benemid)?

Answer 40

allopurinol - prevents uric acid crystals from being made

probenicid - increases excretion of uric acid (by blocking its re-absorption)

Question 41

Your patient has fibromyalgia. What should you rx?

Answer 41

The tricyclic antidepressant Amitriptyline (Elavil)

Question 42

Your pt. has fibromyalgia. What should you NOT rx, because it won’t help?

Answer 42

NSAIDs

Question 43

Your patient has Giant Cell Arteritis. What should you do?

Answer 43

HD prednisone

Emergent referral to ENT

Question 44

YAY! Now what do you deserve?

Answer 44

Some R&R.

Or just grab a drink while you study.

You’re going to do great! :)