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Pre-reg revision > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

Which of these drugs is NOT a DMARD?

  • Methotrexate
  • Gold
  • Leflunamide
  • Colchicine
  • Hydroxychloroquine
A

Colchicine

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2
Q

How long do DMARDs take to work?

A

Varies, but can take 2-6 months for full effect

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3
Q

When should a DMARD be changed for a different one?

A

If not objective benefit in 6-12 months

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4
Q

How does methotrexate work?

A

Anti-folate - inhibtis dihydrofolate reductase

Prevents cellular replication

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5
Q

Dose of MTX for these conditions?

  • RA
  • Crohns
  • Psoriasis
A

RA - max 20mg weekly
Crohns - 10-25mg weekly
Psoriasis - max 30mg weekly

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6
Q

What should a methotrexate prescription include?

A
  • Dose
  • Frequency
  • Only one strength should be prescribed and dispensed
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7
Q

Contra-indications for MTX?

A
  • Active infection - as immunosuppression
  • Ascites - as risk of accumulation
  • Immunodeficiency syndrome
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8
Q

What can increase the risks of toxicity from methotrexate?

A
  • Increasing age
  • Renal impairment
  • Use of other anti-folates eg, trimethoprim
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9
Q

How does the BNF recommend folic acid is used with methotrexate?

A

5mg weekly on a different day to methotrexate

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10
Q

Why is folic acid given with methotrexate?

A

To reduce GI and mucosal side effects and may prevent hepatotoxicity

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11
Q

What advice should be given to patients about contraception whilst on methotrexate?

A

Effective contraception should be used during treatment and for at least 3 months after treatment in both men and women
MTX is teratogenic and fertility may be reduced

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12
Q

Can MTX be used in hepatic and renal impairment?

A
  • Avoid in hepatic impairment unless it is for malignancy

- High doses may be neprotoxic - moniotr renal func

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13
Q

What patient counselling should be given with methotrexate?

A
  • Use effective contraception during + 3 months following treatment
  • Avoid OTC NSAIDs
  • Report any signs of blood disorders, liver toxicity or pulmonary toxicity
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14
Q

What monitoring is required for methotrexate?

A

FBC + renal and liver function tests

Every 2 weeks until treatment stabilised

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15
Q

Which blood disorders may be caused by methotrexate?

A

Decreased WBCS - signs of infection
Decreased RBCs - signs of anaemia
Decreased platelets - bruising and bleeding

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16
Q

What are some interactions with methotrexate?

A

NSAIDs - reduced renal excretion due to vasoconstriction of arteries can lead to toxicity
Drugs with risk of blood disorders - phenytoin, trimethoprim, clozapine etc
Hepatotoxic drugs - isotretinoin, rifampicin, ketoconazole

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17
Q

What monitoring is required for a patient on hydroxychloroquine?

A

Monitor vision/visual changes - risk of ocular toxicity with long-term treatment

  • Before treatment determine baseline vision and renal/liver func and adjust dose if necessary
  • Monitor vison annually and ask pt to report any changes eg, blurred vision
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18
Q

What patient couselling should be given with Leflunomide?

A
  • Risk of blood disorders, report any signs and need FBC monitoring
  • Risk of liver toxicity - do not drink alcohol and LFTs need to be taken every 2 weeks for the first 6/12, potentially life-threatening
  • Contraception is essential during treatment, continue for 2 years after treatment in women and 3 months in men
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19
Q

Why might leflunomide need a ‘wash-out’ with activated charcoal or colestyramine?

A

Has a very long half life

May need a washout if serious side effects occur, before another DMARD is initiated or before conception

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20
Q

How long do men and women who want to concieve have to wait following treatment with leflunomide?

A

Men - 3 months of effective contraception
Women - 2 years following treatment

Sr levels must be <20mcg/L before conception

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21
Q

Can you give penicillamine to a patient with a penicillin allergy?

A

No, patients with penicillin allergy may rarely react to penicillamine

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22
Q

What is sodium aurothiomalate?

A

Gold - DMARD

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23
Q

What are the major side effects of Gold?

A
  • Blood disorders
  • Pulmonary fibrosis - annual chest xray
  • Rashes with pruritis
  • Nephritis + proteinuria, need regular urine tests
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24
Q

Which of these would NOT cause hyperuricaemia/gout?

  • Tacrolimus
  • Cancer
  • Liver impairment
  • Furosemide
  • Chemotherpay
A

Liver impairment

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25
Q

How should an acute gout attack be treated?

A
  1. High doses of NSAIDs
    diclofenac, naproxen, etoricoxib, indometacin, ketoprofen
  2. If NSAIDs C/I then colchicine
  3. Oral/parenteral corticosteroids
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26
Q

Which NSAIDs are NOT indicated in the treatment of an acute gout attack?

A

Ibuprofen + aspirin

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27
Q

How should colchicine be prescribed in an acute gout attack?

A

500mcg 2-4 times/day

No more than 6mg in a course, do not repeat the course within 3 days

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28
Q

How would you treat an acute gout attack in a patient with severe heart failure?

A

Colchicine - no fluid retention

All NSAIDs are contra-indicated in severe heart failure

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29
Q

How should long term prevention for gout be initiated?

A
  • Never in an acute attack, 1-2 weeks after attack has settled
  • Initiation of treatment may precipitate an acute attack, use prophylactic NSAID/colchicine until hyperuricaemia has been corrected for one month
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30
Q

How would you treat an acute gout attack in a patient taking allopurinol?

A
  • Continue allopurinol in same dosage

- Treat attack separately with high-dose NSAIDs/colchicine

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31
Q

What drug is first line for gout prophylaxis?

A

Allopurinol

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32
Q

When used for prophylaxis of hyperuricaemia associated with chemotherpay, when should allopurinol be started?

A

BEFORE chemotherapy

100-200mg daily

33
Q

How should a patient starting allopurinol be counselled?

A
  • Take with food
  • Ensure adequate fluid intake (2-3 L per day)
  • Prophylactic NSAID will need to be taken until hyperuricaemia has been corrected for a month (usually for around 3 months)
34
Q

Can allopurinol be used in renal impairment?

A

Yes

Max 100mg per day

35
Q

What drugs does allopurinol interact with?

A

Mercaptopurine/azathioprine

Reduce dose by 1/2 - 1/4 as risk of toxicity

36
Q

Which drug is 2nd line for gout prophylaxis?

A

Febuxostat

37
Q

How long is a prophylactic NSAID usually needed for when starting febuxostat?

38
Q

Which MHRA warning is associated with febuxostat?

A

Risk of serious hypersensitivity reactions

  • inc SJ syndrome + anaphylaxis
  • Usually happens in first month of treatment
  • Advise pts to recognise signs
39
Q

How dose sulfinapyrazone work?

A

Uricosuric drug - increases excretion of uric acid in the urine

40
Q

Why is it important for patients taking sulfinapyrazone to have adequate urine output?

A

Urine is made alkaline and urea crystals can form

Need good renal function and urine output

41
Q

Can sulfinapyrazone be given to a patient with a hypersensitivity to aspirin?

A

No - avoid if hypersensitivity to aspirin/salicylates

42
Q

When is sulfinapyrazone use cautioned?

A
  • Cardiac disease

- Salt and water retention

43
Q

In which cirumstances can quinine be used for nocturnal leg cramps?

A
  • Sleep is disturbed or cramps are very painful/frequent
  • Treatable causes of cramps have been excluded
  • Non-pharmacological options do not work eg, passive stretching
44
Q

Why is the use of quinine for leg cramps restricted?

A

Can be toxic in overdose

Risk of QT prolongation

45
Q

What side effects are associated with baclofen?

A
  • Drowsiness

- Muscular hypotension

46
Q

Which of these is NOT a reaction caused by abrupt withdrawal of baclofen?

  • Hyperactive state
  • Hypoglycaemia
  • Psychiatric reaction
  • Hyperthermia
  • Convulsions
A

Hypoglycaemia

47
Q

How long do NSAIDs take to work to full effect?

A

Pain relief after first dose
Full analgesia after one week
Anti-inflammatory effect after 3 weeks

48
Q

What is the mechanism of action of NSAIDs?

A

Reduce production of prostaglandins by inhibiting the enzyme cyclo-oxygenase

49
Q

Which NSAIDs selectively inhibit COX-2?

A

Celecoxib, parecoxib, etorocoxib

50
Q

What is high dose ibuprofen?

A

2.4g daily

51
Q

‘Ibuprofen has a weaker anti-inflammatory effect than the other NSAIDs’
True or false?

A

True

Unsuitable if inflammation is prominent eg in gout

52
Q

Which NSAID is the drug of choice for inflammation?

A

Naproxen

Good efficacy and low incidence of side effects

53
Q

When can naproxen be sold OTC?

A

Primary dysmenorrhoea
Women aged 15-50
Max 750mg/day for 3 days (feminax ultra)

54
Q

What side effects are associated with indometacin?

A

Headache, dizziness + GI toxicity (medium)

May affect driving

55
Q

Which side effects with mefenamic acid would mean that the treatment should be discontinued?

A
  • Diarrhoea
  • Haemolytic anaemia
  • Rash
56
Q

Why is piroxicam reserved for specialist use only?

A

High risk of GI toxicity and serious skin reactions

  • Max 20mg OD
  • Review treatment every 2/52
  • Should consider giving with gastro protection
  • Not 1st line, specialist for RA, ASp, OA
57
Q

What side effect is associated with phenylbutazone?

A

Haemotological reactions

58
Q

What are the GI + cardiovascular risks with selective COX-2 inhibitors such as celecoxib?

A

LOW risk for GI side effects

HIGH risk for cardiovascular events

59
Q

Which selective COX-2 inhibitor can be used in gout?

A

Etorocoxib

60
Q

What side effect can be seen with use of topical NSAIDs?

A

Photosensitivity eg, ketoprofen

61
Q

Can you drink alcohol with NSAIDs?

A

Should be fine within daily recommened limits

Alcohol increases risk of GI haemorrhage and AKI has been linked to excess alcohol use with NSAIDs

62
Q

How do NSAIDs affect renal function?

A

Nephrotoxic
They reduce GFR and are renally cleared
Risk in AKI

63
Q

Due to sodium and fluid retention, NSAIDs are cautioned in which conditions?

A

HTN, renal imp, liver imp, congestive heart failure

64
Q

‘All NSAIDs are contra-indicated in severe heart failure’

True or false?

65
Q

Which NSAIDs are commonly used for dental pain?

A

Ibuprofen + diclofenac

66
Q

Why should NSAIDs be avoided in pregnancy?

A
  • Can delay labour or prolong labour
  • Can cause pulmonary hypertension in the newborn
  • Can cause premature closure of foetal ducts
67
Q

Which group of patients are high risk for GI toxicity with NSAIDs?

A

Elderly

Should be given with gastroprotection

68
Q

Which NSAIDs are lowest risk for GI toxicity?

A

Ibuprofen and selective COX-2 inhibitors

69
Q

Which NSAIDs have the highest risk for GI toxicity?

A

Ketoprofen, Ketorolac, Piroxicam

70
Q

Which NSAIDs are intermediate risk for GI toxicity?

A

Naproxen, diclofenac, indometacin

71
Q

Can more than one type of NSAID be used at once?

A

No
NSAID + low dose aspirin = increased GI risk
Only use if absolutely necessary + monitor closely

72
Q

Which NSAIDs are NOT associated with an increased risk of thrombotic events?

A

All NSAIDs are associated with the risk independent of CV risk factors or treatment duration

73
Q

Which NSAIDs have the HIGHEST cardiovascular risk?

A

Diclofenac (150mg)
High dose ibuprofen (2.4g)
Selective COX-2 inhibitors
Acelofenac

74
Q

Which NSAIDs have low cardiovascular risk?

A

Standard dose ibuprofen (< 1.2g)

Naproxen

75
Q

Which is NOT a contra-indication for NSAIDs?

  • Ischaemic heart disease
  • Uncontrolled hypertension
  • Asthma
  • Oedema
  • Left ventricular dysfunction
A

Asthma - but use with caution as can worsen asthma and cause bronchospasm

76
Q

Some interactions with NSAIDS?

A

Risk of AKI - ACEi, ciclosporin, tacrolimus, diuretics
Bleeding risk - warfarin, DOACs, heparin, SSRIs, steroids
Reduced renal excretion (toxicity) - lithium, methotrexate
Hyperkalaemia - K+ sparing diuretics
Convulsions - quinolones

77
Q

What age can children be given ibuprofen OTC?

A

Over 3 months

78
Q

Paediatric doses for ibuprofen?

A 
3-5 months - 50mg TDS
6 - 11 months - 50mg 3-4 times/day
1 - 3 years - 100mg TDS
4 -6 years - 150mg TDS
7 - 9 years - 200mg TDS
10 - 11 years - 300mg TDS
12 - 17 years - 300-400mg 3-4 times per day

Pre-reg revision (14 decks)

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