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Simmons NURP 423 Exam 2 > Musculoskeletal Issues > Flashcards

Musculoskeletal Issues Flashcards

1
Q

What is OA?

A

progressive dx results in chronic pain, restricted, ROM, muscle weakness, ESR <20

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2
Q

What is the primary & secondary cause of OA?

A

1: idiopathic, normal aging
2: traumatic or inherited conditions

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3
Q

What are nonpharmacological ways to treat sx of OA?

A

moist heat, wt loss, exercise to strengthen muscle, keep moving

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4
Q

What are the goals of drug therapy of OA?

A

maintain function, prevent further joint damage, diminish associated pain

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5
Q

What are the sequence of treatment for OA?

A

1st: Tylenol 3,250mg/day
2nd: NSAIDS (due to GI complications)
3rd: Analgesics/Opioid+APAP
4th: intra-articular corticosteroids

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6
Q

What is the MOA of Tylenol?

A

exert action on CNS & inhibit COX, decreasing prostaglandin sythesis. Act as analgesic & anti-pyretic NOT anti-inflammatory

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7
Q

What quality of pain does Tylenol treat?

A

mild to moderate pain

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8
Q

When is Tylenol most effective? Time frame response?

A

around the clock, 1 week

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9
Q

What are cautions & contraindications of Tylenol?

A

> 4gm hepatotoxicity, hepatic dx, >3 ETOH/week. If on chronic Tylenol & warfarin monitor INR

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10
Q

What is an important pt education for Tylenol?

A

Can be found in other meds & take around the clock

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11
Q

What is the MOA for NSAIDS?

A

reversibly inhibit Cox-1 & Cox-2 enzymes which decrease formation of prostaglandin precursors

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12
Q

What meds are Cox-1?Cox-2? Salicyclic acid?

A

Cox-1: Ibuprofen/Motrin/Advil, indomethacin, naproxen, diclofenac
Cox-2: celecoxib/Celebrex
Salicyclic Acid: aspirin

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13
Q

What are advantages to Cox-2? disadvantages?

A
  • less upper and lower GI effects
  • increased risk of CV events, thrombotic events, MI, & stroke (led to removal of COX-2 meds from market except celebrex)
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14
Q

What are the main side effects of NSAIDS?

A

impair platelet aggregation causing bleeding, GIB, ulcers, GI issues, wt gain, HA, perforation, gastric outlet obstruction

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15
Q

What is the time frame for response for NSAIDS?

A

2-3 weeks

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16
Q

What is the max daily dose for ibuprofen? naproxen?

A

ibuprofen <3.2gm/day

naproxen 1,250mg/day

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17
Q

When are NSAIDS contraindicated?

A

sulfa/aspirin allergy, ETOH, renal/hepatic impairment

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18
Q

What is BLACKBOX warning for NSAIDS?

A

thrombotic events, GIB, CVD risk factors, ulcerations, perforations, not give periop for CABG

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19
Q

What is a drug-drug interaction w NSAIDS?

A

ACE & ARB b/c it can cause HTN & affect renal function, avoid NSAID use

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20
Q

Why must you have good kidneys with NSAID use?

A

b/c it can decrease renal perfusion

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21
Q

What medication can you give to combat GI effects of NSAIDS?

A

Prilosec

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22
Q

What must you do when giving NSAIDS to geriatric population?

A

give shorter half-life in smaller dose, Cox-2 or give w misoprostol or PPI. Watch for renal failure & platelet aggregation issues

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23
Q

What are topical NSAIDS? When is it used?

A

voltaren gel, diclofenac. 1st line for pain in hands. Used for acute pain for sprains & strains.

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24
Q

Do topical NSAIDS have same side effects & contraindications/cautions?

A

yes, less systemic but still has all the effects & contraindications

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25
Q

What is the MOA for topical capsaicin?

A

depletion of substance P from peripheral sensory neurons

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26
Q

When would you use capsaicin?

A

for those w renal & liver dysfunction

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27
Q

When is the time frame response for capsaicin?

A

2-4 weeks of continual use

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28
Q

What is a patient education for capsaicin?

A

don’t apply to broken or irritated skin

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29
Q

What are some meds that are analgesics?

A

Tramadol, tapentadol, codeine

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30
Q

What is the MOA of tramadol?

A

mu opioid receptor agonist (inhibit pain pathway, inhibit reuptake of serotonin & norepi

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31
Q

What type of pain would you use Analgesics?

A

moderate pain has no inflammatory effect

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32
Q

What are some side effects of analgesics?

A

nausea, drowsiness, sweating, flushing

ADVERSE: constipation, euphoria, respiratory depression, sedation

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33
Q

Can you take analgesics indefinitely?

A

No, for a limited time due to dependence & withdrawal, when d/c need to taper

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34
Q

What can tramadol induce?

A

serotonin syndrome w SSRI, Tricyclic antidepressants, MAOI, SNRIs, triptans, linezolid

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35
Q

What is the max dose/day for tramadol?

A

400mg

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36
Q

What threshold does tramadol lower?

A

seizure threshold, not for pts w seizure disorder

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37
Q

What is rheumatoid arthritis?

A

chronic autoimmune inflammatory disease characterized by symmetric polyarthritis, joint changes, including erythema, effusion, & tenderness. Pain worse in AM, gets better after warming up

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38
Q

How are ppl dx w RA?

A

ACR/EULAR criteria score >6: based on how many joints involved, serology of RF or ACPA, abnormal CRP or ESR, duration > 6 weeks

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39
Q

What are some non-Rx therapy for RA?

A

PT/OT, warm showers, paraffin tx, hydrotherapy, hot/cold packs

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40
Q

What are goals of therapy for RA?

A
  • reduce pain, stiffness, swelling
  • preserve mobility & joint function
  • prevent further joint damage
  • treating to a goal of remission or low disease activity
41
Q

When would you start DMARDS for RA?

A

start as early as possible (reduces disability & disease progression), start within 3 months of dx. Check LFT’s every 3 months.

42
Q

What are the benefits of using NSAIDS in RA?

A

symptom control & pain relief but has no dx-modifying characteristics

43
Q

When is it ok to use NSAIDS in pregnancy?

A

Best to avoid, due to increase risk of miscarriage early in pregnancy & later in pregnancy early closure of ductus arteriosus

44
Q

Why are corticosteroids used in RA?

A

provide immediate sx relief while initiating DMARDS, used for acute flares, regain control of inflammation & pain

45
Q

What is a typical Prednisone burst for RA?

A

40mg daily x5 days

46
Q

If prednisone given longterm in RA, what is usual dosage? How about in pregnancy?

A

low dose around 5-7.5mg/day. If starting DMARD therapy, 10mg. Pregnancy < 15mg/day.

47
Q

What are conventional synthetic DMARDS?

A

methotrexate, plaquenil, sulfasalazine

48
Q

What is the MOA of methotrexate?

A

folic acid antagonist, affect leukocyte suppression, decrease inflammation from immunological by-products

49
Q

What are common side effects/adverse effects of methotrexate?

A

nausea, abdominal pain, oral ulcers, leukopenia, anemia, thrombocytopenia
Adverse: liver toxicity in DM, obesity, ETOH. opportunistic infxn

50
Q

What is time frame for benefits of methotrexate?

A

3-8 weeks for some benefits. 3-6 months for full benefits

51
Q

What are baseline labs/tests for methotrexate?

A

xray, CBC, liver function test, BUN/Cr, screen for infection

52
Q

What are contraindications to methotrexate?

A 
Pregnancy X (stop use 1 cycle before becoming pregnant)
Breastfeeding
Leukopenia (WBC<3)
Immunodeficiency
Renal Impairment (Cr<30)
Liver Disease
53
Q

What are blackbox warning for methotrexate?

A

platelets <50, latent TB, active fungal infx, active herpes zoster, renal impairment, hepatotoxicity

54
Q

What are patient education with methotrexate?

A
  • report any dry cough, dyspnea, fevere

- avoid alcohol use

55
Q

What is the MOA of sulfasalazine?

A

Conversion to sulfapyridine & 5-acetylsalicylic acid in gut (anti-inflammatory conversion, decrease cytokine production)

56
Q

What is sulfasalazine best indicated for in RA?

A

BEST for significant synovitis, but no poor prognostic factors
relieve sx quickly.

57
Q

What are side/adverse effects of sulfasalazine?

A

n/dia, intestinal or urinary obstruction, oral ulcers, thombocytopenia
Reversible sterility
Agranulocytosis

58
Q

What is time frame response for sulfasalazine?

A

effect in 1month, full in 4 months

59
Q

What labs will you monitor in sulfasalazine?

A

CBC & liver enzymes

60
Q

What is contraindicated in sulfasalazine?

A

Sulfa allergy component
G6PD deficiency

Cat D at full term
GI/GU obstruction
Poryphyria (blood disorder)
Platelets <50
2x liver enzymes
Hep B/C
61
Q

What are some drug/drug interactions w sulfasalazine?

A

Oral hypoglycemics
Oral anticoagulants
cyclosporine

62
Q

What is the MOA for hydroxychloroquine?

A

inhibit antigen processing by elevating cellular pH, impair presentation

63
Q

What is hydroxychloroquine best indicated for?

A

Cannot limit progression of RA but more tolerable. Usually adjunct to methotrexate or mono early for mild RA w/ bone erosion

64
Q

What are some side effects of hydroxychloroquine?

A

photosensitivity, skin pigment change, maculopapular rash, neuromyopathy

65
Q

When do you see therapeutic effects for hydroxychloroquine?

A

2-6 months

66
Q

What are baseline labs/tests for hydroxychloroquine?

A

eye exam & CBC

67
Q

What are some biologic DMARDS?

A

Tumor Necrosis Factor Inhibitors

  • infliximab/Remicade
  • etanercept/Enbrel
  • adulimumab/Humira
68
Q

What are MOA of biologic DMARDS?

A

Binding circulating TNF-alpha & render it inactive
Chemotactic effect of TNF-alpha by reducing IL-6 & CRP, result in reducing infiltration of inflammatory cells into joints
“Reduce penetration of inflammatory cells into joints”

69
Q

What are adverse effects of bDMARDS?

A

demyelinating CNSD, autoimmune disorders: lupus-like, lymphomas NOT for solid malign <5yo or lymph malignancy

70
Q

What is the time frame response for bDMARDS? Baseline labs/tests?

A

Rapid response, days to weeks

Baseline: xray, CBC, liver fxn test, B/Cr

71
Q

What are contraindications for bDMARD?

A 
Pregnancy B-caution
Latent TB
Fungal infxn
Hep B
Class III or IV CHF

NO LIVE VACCINE & NOT w other BIOLOGICS

72
Q

What are EULAR Tx recommendations for RA?

A

Phase I: Methotrexate mono or combo. If Methotrexate contraindicated: leflunomide or sulfasalzine alone or combo
Phase II: Failure of phase I
- w poor prognosis OR failure of 2nd csDMARD, BDMARD
-w/o poor prognosis, change csDMARDs
- Phase III: failure of bDMARD, use alternate bDMARD. (if fail again then tofacitinib)

73
Q

What is gout?

A

Monosodium urate crystals precipitating in the synovial fluid between joints due to hyperuricemia (6.8mg/dL)
overproduction of
Best tx is allopurinol
Or underexcretion of uric acid (CKD, DM, on thiazide & loop diuretics, cyclosporineASA)
Best tx is probenecid, pegloticase

74
Q

How would you treat acute gout?

A 
Short course:
1st Line:
NSAIDS, usually 3-7 days, continue 24h after resolution.(acute attacks &amp; pain) 
Naproxen
Indomethacin
Sulindac
OR	
Systemic corticosteroids
OR
Colchicine
2nd Line:
Any combo EXCEPT NSAIDS &amp; corticosteroids

Ice therapy

75
Q

How would you treat chronic gout?

A

Urate-lowering therapies (ULT)
Gout flares can occur when initiating therefore start:
NSAIDS or colchicine for 1st 6mo of therapy
1st line: Xanthine Oxidase Inhibitiors(maintenance)
2nd line: probenecid
Last: pegloticase

76
Q

What drugs are Xanthine Oxidase Inhibitors? What is it’s MOA?

A

Decrease uric acid level by selectively inhibiting xanthine oxidase, inhibit urate formation

allopurinol
Febuxostat

77
Q

When are Xanthine Oxidase Inhibitors best indicated for?

A

1st line therapy for chronic gout

Start after flare is done (1st tx w NSAID/steroid)

For overproducers

78
Q

What are Xanthine Oxidase Inhibitors side/adverse effects?

A

Allopurinol
Increase risk for hypersensitivity (Drug induced eosinophilia)
(Stevens-Johnson syndrome, impaired liver,kidney function, leukocytosis, & eosinophilia), worsens w ACEI, thiazides, & loop diuretics
dose adjust kidney failure

Adverse:
Rash
Arthralgias
GI complications

79
Q

What is the time frame response for Xanthine Oxidase Inhibitors? What are we monitoring?

A

Serum urate levels begin to fall >2 weeks, draw level 2-5 weeks to titrate, then q6mo

Labs: LFTs

Careful monitoring w warfarin

80
Q

What drugs is Xanthine Oxidase Inhibitors contraindicated?

A

Do not administer w pegloticase, didanosine, azathioprine, mercatopurine

81
Q

What is the MOA of probenecid?

A

probenecid

Increase excretion of serum uric acid by inhibiting the reabsorption of uric acid at PCT

82
Q

When would you use probenecid?

A

2nd line to replace XOI for chronic gout

For undersecreters

83
Q

What are side effects/adverse effects for probenecid?

A 
Side Effects:
n/v
Dizziness
HA
Anorexia
Dermatitis
Gout exacerbations

Adverse:
G6PD deficiency can have hemolytic anemia & aplastic anemia

84
Q

What is the time frame response for probenecid?

A

Serum uric acid levels begin to decrease 2 weeks, up to 6mo full effect

85
Q

What are cautions & contraindications w probenecid?

A

Not given during acute gout attack, can exacerbate, blood dyscrasias, uric acid kidney stones, w ketorolac

Avoid w PCN, cephalosporins, fluoroquinolones, celexa, methotrexate, pegloticase, ASA

86
Q

What is the MOA of pegloticase?

A

pegloticase

Pegylated recombinant form of uricase (converts uric acid to allantoin that is a metabolite that allows uric acid to be easily excreted by kidneys)

87
Q

When would pegloticase be indicated?

A

Last line for chronic gout- dc all other antihyperuricemic agents

Very expensive, IV q2 weeks

88
Q

What are some side effects of pegloticase?

A

n/v

constipation

89
Q

What is the time frame response for pegloticase?

A

reduction of uric acid in 1d-6mo

90
Q

What are contraindications of pegloticase?

A

G6PD deficiency

BLACKBOX: hypersensitivity anaphylaxis

91
Q

What are patient education points for pegloticase?

A

Start NSAIDS or colchicine to prophylaxis 1 week before start x6mo prevent flares

Before infusion antihistamines & corticosteroid

92
Q

What is the MOA for prednisone?

A

prednisone
Methylprednisone

Inhibits multiple inflammatory cytokines, produces multiple glucocorticoid & mineralcorticoid effects

Decrease inflammation by suppressing migration of polymorphonuclear leukocytes

93
Q

What are side effects/adverse effects of prednisone? What supplement would you ensure they take?

A 
Cushingoid appearance
Hursutism
Wt gain
Erythema
Appetite change
HTN
Fluid retention
Dyspepsia
osteoporosis
Adverse: 
Hyperglycemia
CNS stimulation
Cutaneous atrophy
Glaucoma
Cataracts

Calcium 1,500mg w Vit D 800mg/day

94
Q

What is the MOA of colcicine?

A

Colchicine NSAID

Inhibit activation, degranulation, & migration of neutrophils to area of gout attack

Decrease deposits of uric acid & phagocytosis

95
Q

What are side effects of colchicine? When do you adjust dose? How long is therapy?

A

Diarrhea!!!!!
pharyngolaryngeal pain, fatigue, HA

Decrease dose for CrCl<30 & not repeat dose in 2 weeks

Taken prophylactic <6mo therapy

96
Q

What is time frame of response for colchicine?

A

Give 1st dose within 24h of sx onset

Pain relief in 18-24h

Inflammation effect 48h

97
Q

What is contraindicated w colchicine?

A

CYP3A4 inhibitor

Renal & hepatic impairment

98
Q

What would you educate a woman taking methotrexate of childbearing years?

A

must use contraception & inform when you intend to get pregnant

99
Q

What meds can be give for tx of RA in pregnancy?

A

antimalarials, sulfasalazine, azathioprine, cyclosporine as mono or combo. Corticosteroids <15mg/d

Simmons NURP 423 Exam 2 (4 decks)

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