Musculoskeletal Flashcards
what is rhermatoid arthritis?
pain and stiffness, worsens with rest, inactivity and heat in the joints
what are the drug options for rheumatoid arthritis?
1st line = methotrexate, leflunomide or sulfasalazine
2nd - MAbs
what does DMARDs stand for?
disease modifying anti rheumatic drugs
what DMARD is used in mild RA?
hydroxychloroquine
what MAbs can be used for RA?
adalimumab, infliximad, etanercept, tozlizumab
what can you give is someone with RA is in severe pain and need of treatment whilst waiting for methotrexate to work?
can bridge with corticosteroids
NSAIDs can also be used by need to withdraw when methorexate given
what red flags symptoms need an urgent referral with methotrexate?
signs of blood disorders
liver toxicity
respiratory effects
gastro toxicity
how many times a week in folic acid taken when rxd methotrexate?
6 days a week - not on same day
whats the antidote for methotrexate?
folininc acid
what tests need to be done for methotrexate monitoring?
FBC, renal profile, LFTS
every 1 - 2 weeks until stable
then every 2 - 3 weeks after
if a male is taking methotrexate, does their partner need to be on contraception?
does contraception need to be continued post treatment?
yes need effective contraception during treatment and at least 6 months after for both men and women
what are the 4 types on interactions to look out for with methotrexate?
- nephtotoxic drugs as MTX reduced renal function hence why need to avoid NSAIDs
- anti-folates (trimethprim, phenytoin)
- hepatotoxic (rifampicin, antifungals)
- PPIs - reduce clearance = increased toxicity
what are some of the cuases of gout?
diet (high salt, fat, alcohol)
bendroflumethiazide
chemotherapy drugs
whats the acute management of gout?
- colchicine or high dose NSAID + PPI
dose of colchicine = 500mcg 2 -4 times a day max TDS
how long do you need to leave before repeating course of colchicine?
do not repeat courses within 3 days
when would you avoid using NSAIDs to treat gout?
in people on diuretics due to fluid retention
what are less common options for acute gout management?
short course or oral corticosteroid
IM injection of corticosteroid or canakinumab
when do you offer chronic treatment for gout?
what is the 1st and 2nd line?
2 or more attacks in a year
1st line = allopurinol
2nd = febuxostat
what do you do if someone has an acute gout attack whilst on chronic gout treatment?
continue chronic treatment whilst taking colchicine
whats the most common SE with allopurinol?
rash, hypersensitvity
discontinue, if mild cna restart with caution, may need to stop
what do you need to do with the dose of azathioprine/mercaptopurie if given with allopurinol?
reduce the dose of azathioprine/mercaptopurine due to interaction
what is used for nocturnal leg cramps?
how long do you trial before assessing benefit?
is this a recommended option?
quinne sulfate
trial for 4 weeks, only continue if benefit - need to stop and review treatment every 3 months
not routinely recommended, only if disrupts sleep or are very painful
what patients do you need to avoid NSAIDs?
asthmatics - increased risk of bronchospasams
what are the 2 main side effects of NSAIDs?
GI and cardiac
which NSAIDs have the highest risk of GI SE?
piroxicam, ketoprofen, ketorolac
what NSAIDs have the lowest risk of GI effects?
celeoxib, etoricoxib (COX-2 selective inhibitors)
what NASIDs have a higher risk of GI SE out of naproxen, diclofenac, indometacin and ibuprofen?
ibuprofen has the lowest risk out of those listed but not as low of celeoxib and etoricoxib
what NSAIDs have the highest and lowest risk of CV effects?
Highest = COX-2selective (celecoxib, etoricoxib), diclofenac, high dose ibuprofen (2.4g)
Lowest = naproxen, ibuporfen 1.2g
can NSAIDs be used in pregnancy and breastfeeding?
avoid in pregnancy
caution in breastfeeding
what things can increase the risk fo GI bleeds if given with NSAIDs?
low dose aspirin and alcohol - need PPI cover especially in elderly
what should you do if someone has a known sensitivity to aspirin?
caution due to hypersenstivity reactions and cross senstivity with aspirin
can NSAIDs be used in renal impairment?
no due to fluid retention and further impairment
whats the risk of giving NSAID with MTX/lithium?
reduces the clearance of these drugs = increases toxicity
whats the risk if NSAIDs given ith ciprofloxacin?
increases risk of seizures
whats the risk if NSAIDs gven with other drugs which raise K+?
hyperkalaemia ‘tequila always makes nurses smile’
