MUSCULOSKELETAL Flashcards by thurica jeyaselan

What is rheumatoid arthritis?

Immune system attack synovium= causes inflammation

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What are 3 symptoms of rheumatoid arthritis?

Joint pain - swollen, heat, stiff, motion loss

Rheumatic nodules

affect hands + feet

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What are 4 specific symptoms of rheumatoid arthritis?

malaise, fatigue, fever, and weight loss

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What is Palindromic rheumatism?

Rare form of inflammatory arthritis.

Causes attacks of joint pain & swelling similar to rheumatoid arthritis, but joints return to normal in between attacks.

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What is 1st line drug treatment for rheumatoid arthritis?

Conventional DMARD

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What is 2nd line drug treatment for rheumatoid arthritis?

Combination therapy

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What is 3rd line drug treatment for rheumatoid arthritis?

Cytokine modulators e.g. (TNF) alpha inhibitor

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What 2 drugs are given for severe active RA?

Mtx + rituximab

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What drug is used to manage short-term bridging treatment or flare up of RA?

Steroids

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What 5 drugs effect immune response which are DMARDS?

MTX

azathioprine

ciclosporin

cyclophosphamide

leflunomide

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What DMARD requires contraceptive after treatment + is hepatotoxic?

leflunomide

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What 2 antimalarial drugs are DMARDS?

hydroxychloroquine

Chloroquine

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What 3 cytokine modulators are are DMARDS?

TNF a inhibitor

targeted synthetic

Other biological

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What DMARD colours urine + produces orange tears?

Sulfasalazine

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What is MOA of methotrexate?

Blocks dihydrofolate reductase = prevents purine/ pyrimidine production

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What are 4 conditions MTX is used in?

Crohn’s disease

Psoriasis

Cancer

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What should MTX be prescribed by?

Brand

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What counts as a missed dose of MTX?

More than 2 days of not taking

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What is dosing for mtx?

Once weekly

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What is a MHRA warning for mtx?

Once weekly for autoimmune diseases - specific day each week.

Do not take daily, report overdose, provide pt with alert card + treatment booklet.

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What is given with mtx to reduce SE?

Folic acid

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What are the possible folic acid regimens?

5mg weekly- diff day to mtx day

1 or 5mg OD- except mtx day

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What are 5 main SEs of MTX?

Blood disorders

nephrotoxicity

hepatotoxicity

Pulmonary toxicity

GI toxicity

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What is antidote for mtx overdose?

folinic acid rescue

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Can mtx be taken in pregnancy?

NO- teratogenic - contraceptive

How long is contraceptive needed for men + women for MTX

During + 6 M after

How to handle mtx?

Avoid contact with skin + avoid in pregnant women

What is monitored for mtx?

LFTs, FBC, renal - every 1 to 2 weeks until stable. Then 2-3 monthly

What symptoms should be reported if patient on mtx?

Infection, sore throat

What 2 GI issues to stop MTX in?

Stomatitis or diarrhoea

What is the issue if there are symptoms of persistant vomiting, abdo pain, dark urine + jaundice?

Hepatotoxicity

What are 3 main contra-indications of MTX?

Ascites, active infection, significant plural effusion (lung)

What should be done to mtx in renal impairment?

Reduce dose

What 5 drugs can interact with mtx to increase blood disorders?

Trimethoprim** Clozapine Phenytoin Cytotoxic drug immunosuppressant

What 3 drug classes interacts with MTX to increase toxicity due to reduced renal clearance?

NSAIDS Penicillin PPI

What 5 drugs/classes interact with MTX to increase nephrotoxicity?

Aminoglycosides, cephalosporin, glycopeptide, ciclosporin/tac, NSAID

What 6 drugs interact with MTX to increase hepatotoxicity?

Statin, co-amoxiclav, flucloxicillin + tetracyclines, carbamazepine, sodium valproate, fluconazole, isoniazid

What is osteoarthritis?

cartilage wears down + prevents smooth movement.

What is 1st line treatment for arthritis?

Topical NSAID

What is 2nd line treatment for arthritis if topical NSAID does not work?

Oral NSAID -- if not then, Paracetamol/weak opioid for short term

What are 2 symptoms of osteoarthritis?

Joint pain - stiff, motion loss Affects weight- bearing joints

What are used in polyarthritis, oligoarthritis?

DMARDs

What helps manage pain pain associated with osteoarthritis if knee involved?

Topical capsaicin 0.025%

What is Spondyloarthritis?

group of inflammatory musculoskeletal conditions with shared features which affect both axial & peripheral joints.

What is gout?

Type of arthritis, where uric acid forms on big toe

What is drug tx for Spondyloarthritis?

Refer specialist if need help with day to day activities. Hydrotherapy - add on to improve symptoms.

What is Spondyloarthritis 1st line tx?

NSAIDS - if at max dose for 2 to 4 weeks, switch to another.

monoarthritis 1st line?

Local steroid injections

What 3 drug classes are used in specialist care for ankylosing spondylitis?

Janus kinase (JAK) inhibitors, biological drugs, (TNF-a) inhibitors

What are 3 symptoms of gout?

Joint pain- sudden, intense, swollen. purple red shiny skin Tophi

What 3 types of drugs cause gout?

Loop/thiazide diuretic cytotoxic drugs ciclosporin + tacrolimus

What are 3 treatment options for acute attacks of gout?

either: Colchicine, high doses of an NSAID, oral corticosteroid

What NSAID is avoided for gout?

Aspirin

What is monitored in long term tx of colchicine?

FBC periodically in patients on long-term therapy.

What is 1st line tx for prevention of gout?

Allopurinol or febuxostat

What can colchicine be given with safely?

Anticoagulants

What 4 types of patients should be on urate lowering tx for gout?

multiple or troublesome acute attacks chronic gouty arthritis, CKD stages 3 to 5, large crystal deposits (tophi), those on diuretic therapy

What is a contra-indication of colchicine?

Blood disorders

What is target target serum urate level in gout?

Below 360 micromol/litre.

What is target target serum urate level in gout for patients with tophi, frequent flares?

below 300 micromol/litre

When should long term gout treatment be started?

at least 2 to 4 weeks after a gout flare has settled but if frequent, then can be started early.

What can happen if urate-lowering therapy is increased?

Precipitate an acute attack, therefore colchicine should be offered as prophylaxis while the target

What are 2 MHRA warnings linked to febuxostat?

Hypersensitivity Increased risk of CVD + mortality

What class are allopurinol + fuboxustat?

Xanthine oxidase inhibitor

What is a label for allopurinol?

Take with or just after food with glass of water.

What is a SE of allopurinol?

Rash -stop and if mild carry on but if it appears, then stop

What to do with allopurinol if giving with azathioprine + mercaptopurine?

Reduce dose to 1/4 of azathioprine as toxic

What drug is for nocturnal leg cramps?

Quinine

What are 2 SEs of quinine?

Toxic - overdose, convulsions + arrhythmias Blindness, tinnitus QT prolongation

What is a MHRA alert related to quinine?

QT prolongation- dose dependent

What are 2 symptoms of quinine overdose?

Arrhythmias, convulsions

What is used for severe spasticity + palliative care?

Baclofen

What is route of baclofen?

Intrathecal - test dose + monitor, resus

What are 3 SEs of baclofen?

Drowsy - driving x Muscular hypotonia avoid stopping suddenly

1st line for ocular myasthenia gravis?

Anticholinesterases

1st line generalised myasthenia gravis?

Immunosuppresant + Anticholinesterases (add on. Neostigmine)

anticholinesterases SEs?

Muscarinic Sweating increased salivary and gastric secretions, increased gastro-intestinal and uterine motility, and bradycardia

What helps treat muscarininc SEs?

atropine sulfate.

1st line symptomatic treatment of Lambert-Eaton myasthenic syndrome (LEMS)?

Amifampridine

What drug helps improve walking in patients with MS who have a walking disability?

Fampridine

MOA of NSAIDS?

Blocks COX enzymes involved in making prostaglandins

What 3 drugs are COX2 selective?

Celecoxib etoricoxib Parecoxib

What NSAIDs are non-selective

ASPIRIN Diclofenac ibuprofen naproxen indometacin

What is 6 main SEs of NSAIDS?

Asthma + dyspnoea Hypersensitivity Photosensitive - topical Nephrotoxic Bleeding hyperkalaemia HTN Oedema

What cardiac SE does NSAID have?

Worsens HF, RI + LI - oedma caused

Can NSAIDs be used in pregnancy?

No -Avoid in 3rd timerster

What does NSAID do on 3rd timerster?

premature closure of foetal ductus in utero Delays onset of labour + increases duration Pulmonary HTN in baby :(

When to take NSAIDS?

With or after food

What 2 drugs increase NSAID toxicity via reduced renal clearance?

Lithium MTX

What 3 NSAIDS have higher risk of GI toxicity?

Piroxicam Ketoprofen Kerorolac

What 2 NSAIDs have low risk of GI toxicity?

COX2 selective, Ibuprofen less than 1 .2g

What are 4 contraindications of NSAIDS?

Ative ulcer/bleeding NSAID induced hx Recurrent hx of bleeding >2 episodes

What heart related conditions are NSAIDS contra in?

Severe HF

What 3 NSAIDS are high risk of CVD?

COX 2 selective High dose ibu 2.4g Diclofenac 150mg daily

What is extravasation injury?

leakage of drugs or IV fluids from the veins or inadvertent administration into the subcutaneous or subdermal tissue

What type of preps can increase likelihood of extravasation injury?

Acidic or alkaline preparations e.g. alcohol, PEG

How to improve the patency of the vessel in patients with small veins?

GTN patch distal to the cannula

How to manage extravasation?

Stop Infusion Cannula should NOT be removed until after aspirate area to remove drug Corticosteroids given for inflammation