Musculoskeletal

Question 1

What drugs are considered DMARDs?

Answer 1

Methotrexate, cytokine modulators, azathioprine, ciclosporin, cyclophosphamide, leflunomide, penicillamine, gold, antimalarials and sulfasalazine.

Question 2

What is the next step in pain relief for a patient taking 75mg aspirin, 4g paracetamol, 5mg Ramipril and 20mg simvastatin daily with osteoarthritis.

Answer 2

Opioid. Considered before NSAID if taking low dose aspirin.

Question 3

Is paracetamol or an NSAID started in first instance with axial spondyloarthritis?

Answer 3

NSAIDs

Question 4

What combination is given to patients newly diagnosed with active rheumatoid arthritis and within what ideal time frame?

Answer 4

DMARD and short term corticosteroid. Ideally within 3 months of onset of persistent symptoms.

Question 5

How long does leflunomide take for therapeutic effect to start?

Answer 5

4 - 6 weeks

Question 6

Which drugs are most commonly used in juvenile idiopathic arthritis?

Answer 6

Methotrexate, sulfasalazine if not systemic onset. Cytokine modulators.

Question 7

What monitoring requirements are there with hydroxychloroquine?

Answer 7

Opthalmological examination and continue to ask about visual symptoms

Question 8

A patient is 90kg and 165cm tall, the maximun dose this patient can receive in a day is 585mg (6.5mg/kg). True or false.

Answer 8

False. Must use ideal body weight

Question 9

What monitoring and advice is given with leflunomide?

Answer 9

Discontinue treatment or reduce dose with liver function abnormalities. Use contraception at least 2 years after treatment and 3 months in men unless washout procedure used (colestyramine/charcoal) until metabolise less than 20mcg/l. Monitor FBC and blood pressure also.

Question 10

What advice should be given with penicillamine?

Answer 10

Must go for regular tests for platelets and proteinuria - can be a sign of nephropathy. Discontinue if toxicity occurs. Tell doctor if sore throat, fever, bleeding, bruising, mouth ulcers or rashes occur.

Question 11

What is used in acute gout?

Answer 11

High dose NSAIDs. Colchicine if contraindicated eg heart failure where fluid retention would occur, or when recieveing anticoagulants.

Corticosteroids, canakinumab

Question 12

When are xanthine oxidase inhibitors started? What may be started alongside?

Answer 12

1 - 2 weeks after an episode of gout has settled, to prevent further. Antiinflammatories or colchicine should be used as they can precipitate an actual attack, and continue for one month after Hyperuricaemia corrected (3-6 months)

Question 13

What should be advised with allopurinol treatment?

Answer 13

Ensure adequate fluid intake (2-3 litres per day) especially in first few weeks or with cancer therapy. Rash may occur and discontinue (may reintroduce if mild)

Question 14

What action should be taken if an acute attack of gout occurs while on prophylactic therapy?

Answer 14

Continue prophylactic and treat attack as well

Question 15

Do anticholinesterases enhance or impair neuromuscular transmission?

Answer 15

Normally enhance. But impair at excessive dosage

Question 16

What side effects are associated with anticholinesterases? What drugs may be given alongside?

Answer 16

Sweating, increased saliva, gastro intestinal and uterine motility and bradycardia. Antimuscarinics eg atropine or propantheline.

Question 17

How are pyridostigmine and neostigmine compared?

Answer 17

Pyridostigmine less powerful and slower but longer duration of action (less frequent dosing). Better for patients whose muscles are weak on waking and it’s smoother action

Question 18

How should baclofen be introduced and stopped and why?

Answer 18

Slowly to avoid major side effects of sedation and muscular hypotonia. Stopped over 1-2 weeks also.

Question 19

How long until quinine is effective and how often should it be reviewed?

Answer 19

Up to 4 weeks and review every 3 months.

Question 20

What should be monitored with tizanidine?

Answer 20

Liver function monthly and in unexplained nausea anorexia or fatigue. Discontinue if enzymes persistently raised.

Monitor blood pressure on withdrawal and risk of rebound hypertension and tachycardia. (discontinue gradually)

Question 21

How long does the anti inflammatory effects of NSAIDs take to achieve?

Answer 21

Up to 3 weeks

Question 22

Are the risks of serious upper GI events higher with selective or non selective COX inhibitors? Examples?

Answer 22

Non selective
Piroxicam, ketoprofen, ketorolac highest risk.
Indomethacin Diclofenac, naproxen intermediate

Question 23

Which NSAIDs are associated with higher risk of thrombotic events?

Answer 23

Diclofenac, naproxen and ibuprofen. Etoricoxib

Question 24

What can occur with alcohol consumption and NSAIDs?

Answer 24

Haemorrhage and AKI

Question 25

Which is most suitable for lower back pain if NSAIDs are not suitable - opioid or paracetamol?

Answer 25

Opioid alone or with paracetamol. Paracetamol alone is ineffective.

Question 26

What risks are associated with nsaid use in pregnancy?

Answer 26

Closure of fetal ductus arteriosus in utero and pulmonary hypertension if used in third trimester. Onset of labour may be delayed and duration increased.

Question 27

What extra advice should be given to females using NSAIDs?

Answer 27

Long term use is associated with reduced fertility. Reversible on stopping.

Question 28

What is often done to prevent relapse when reducing corticosteroid doses in rheumatoid arthritis?

Answer 28

Pulse doses

Question 29

What doses of prednisolone are given in rheumatoid arthritis? How long?

Answer 29

Under 7.5mg daily for 2 - 4 years

Question 30

How is extravasation managed?

Answer 30

Corticosteroids, antihistamines, analgesics.
Localise and neutralise - vesicant drugs using antidote and cold compress 3-4 times daily
Or spread and dilute - saline, warm compress, elevation, hyaluronidase.

Question 31

What are the different strengths of capsaicin used fir?

Answer 31

0.025% for hand or knee osteoarthritis
0.075% postherpetic neuralgia after lesions or diabetic neuropathy
8% non diabetic neuropathic pain