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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
What is the MOA for topical capsaicin?
depletion of substance P from peripheral sensory neurons
26
When would you use capsaicin?
for those w renal & liver dysfunction
27
When is the time frame response for capsaicin?
2-4 weeks of continual use
28
What is a patient education for capsaicin?
don't apply to broken or irritated skin
29
What are some meds that are analgesics?
Tramadol, tapentadol, codeine
30
What is the MOA of tramadol?
mu opioid receptor agonist (inhibit pain pathway, inhibit reuptake of serotonin & norepi
31
What type of pain would you use Analgesics?
moderate pain has no inflammatory effect
32
What are some side effects of analgesics?
nausea, drowsiness, sweating, flushing | ADVERSE: constipation, euphoria, respiratory depression, sedation
33
Can you take analgesics indefinitely?
No, for a limited time due to dependence & withdrawal, when d/c need to taper
34
What can tramadol induce?
serotonin syndrome w SSRI, Tricyclic antidepressants, MAOI, SNRIs, triptans, linezolid
35
What is the max dose/day for tramadol?
400mg
36
What threshold does tramadol lower?
seizure threshold, not for pts w seizure disorder
37
What is rheumatoid arthritis?
chronic autoimmune inflammatory disease characterized by symmetric polyarthritis, joint changes, including erythema, effusion, & tenderness. Pain worse in AM, gets better after warming up
38
How are ppl dx w RA?
ACR/EULAR criteria score >6: based on how many joints involved, serology of RF or ACPA, abnormal CRP or ESR, duration > 6 weeks
39
What are some non-Rx therapy for RA?
PT/OT, warm showers, paraffin tx, hydrotherapy, hot/cold packs
40
What are goals of therapy for RA?
- reduce pain, stiffness, swelling - preserve mobility & joint function - prevent further joint damage - treating to a goal of remission or low disease activity
41
When would you start DMARDS for RA?
start as early as possible (reduces disability & disease progression), start within 3 months of dx. Check LFT's every 3 months.
42
What are the benefits of using NSAIDS in RA?
symptom control & pain relief but has no dx-modifying characteristics
43
When is it ok to use NSAIDS in pregnancy?
Best to avoid, due to increase risk of miscarriage early in pregnancy & later in pregnancy early closure of ductus arteriosus
44
Why are corticosteroids used in RA?
provide immediate sx relief while initiating DMARDS, used for acute flares, regain control of inflammation & pain
45
What is a typical Prednisone burst for RA?
40mg daily x5 days
46
If prednisone given longterm in RA, what is usual dosage? How about in pregnancy?
low dose around 5-7.5mg/day. If starting DMARD therapy, 10mg. Pregnancy < 15mg/day.
47
What are conventional synthetic DMARDS?
methotrexate, plaquenil, sulfasalazine
48
What is the MOA of methotrexate?
folic acid antagonist, affect leukocyte suppression, decrease inflammation from immunological by-products
49
What are common side effects/adverse effects of methotrexate?
nausea, abdominal pain, oral ulcers, leukopenia, anemia, thrombocytopenia Adverse: liver toxicity in DM, obesity, ETOH. opportunistic infxn
50
What is time frame for benefits of methotrexate?
3-8 weeks for some benefits. 3-6 months for full benefits
51
What are baseline labs/tests for methotrexate?
xray, CBC, liver function test, BUN/Cr, screen for infection
52
What are contraindications to methotrexate?
``` Pregnancy X (stop use 1 cycle before becoming pregnant) Breastfeeding Leukopenia (WBC<3) Immunodeficiency Renal Impairment (Cr<30) Liver Disease ```
53
What are blackbox warning for methotrexate?
platelets <50, latent TB, active fungal infx, active herpes zoster, renal impairment, hepatotoxicity
54
What are patient education with methotrexate?
- report any dry cough, dyspnea, fevere | - avoid alcohol use
55
What is the MOA of sulfasalazine?
Conversion to sulfapyridine & 5-acetylsalicylic acid in gut (anti-inflammatory conversion, decrease cytokine production)
56
What is sulfasalazine best indicated for in RA?
BEST for significant synovitis, but no poor prognostic factors relieve sx quickly.
57
What are side/adverse effects of sulfasalazine?
n/dia, intestinal or urinary obstruction, oral ulcers, thombocytopenia Reversible sterility Agranulocytosis
58
What is time frame response for sulfasalazine?
effect in 1month, full in 4 months
59
What labs will you monitor in sulfasalazine?
CBC & liver enzymes
60
What is contraindicated in sulfasalazine?
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
What are some drug/drug interactions w sulfasalazine?
Oral hypoglycemics Oral anticoagulants cyclosporine
62
What is the MOA for hydroxychloroquine?
inhibit antigen processing by elevating cellular pH, impair presentation
63
What is hydroxychloroquine best indicated for?
Cannot limit progression of RA but more tolerable. Usually adjunct to methotrexate or mono early for mild RA w/ bone erosion
64
What are some side effects of hydroxychloroquine?
photosensitivity, skin pigment change, maculopapular rash, neuromyopathy
65
When do you see therapeutic effects for hydroxychloroquine?
2-6 months
66
What are baseline labs/tests for hydroxychloroquine?
eye exam & CBC
67
What are some biologic DMARDS?
Tumor Necrosis Factor Inhibitors - infliximab/Remicade - etanercept/Enbrel - adulimumab/Humira
68
What are MOA of biologic DMARDS?
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
What are adverse effects of bDMARDS?
demyelinating CNSD, autoimmune disorders: lupus-like, lymphomas NOT for solid malign <5yo or lymph malignancy
70
What is the time frame response for bDMARDS? Baseline labs/tests?
Rapid response, days to weeks | Baseline: xray, CBC, liver fxn test, B/Cr
71
What are contraindications for bDMARD?
``` Pregnancy B-caution Latent TB Fungal infxn Hep B Class III or IV CHF ``` NO LIVE VACCINE & NOT w other BIOLOGICS
72
What are EULAR Tx recommendations for RA?
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
What is gout?
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
How would you treat acute gout?
``` Short course: 1st Line: NSAIDS, usually 3-7 days, continue 24h after resolution.(acute attacks & pain) Naproxen Indomethacin Sulindac OR Systemic corticosteroids OR Colchicine 2nd Line: Any combo EXCEPT NSAIDS & corticosteroids ``` Ice therapy
75
How would you treat chronic gout?
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
What drugs are Xanthine Oxidase Inhibitors? What is it's MOA?
Decrease uric acid level by selectively inhibiting xanthine oxidase, inhibit urate formation allopurinol Febuxostat
77
When are Xanthine Oxidase Inhibitors best indicated for?
1st line therapy for chronic gout Start after flare is done (1st tx w NSAID/steroid) For overproducers
78
What are Xanthine Oxidase Inhibitors side/adverse effects?
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
What is the time frame response for Xanthine Oxidase Inhibitors? What are we monitoring?
Serum urate levels begin to fall >2 weeks, draw level 2-5 weeks to titrate, then q6mo Labs: LFTs Careful monitoring w warfarin
80
What drugs is Xanthine Oxidase Inhibitors contraindicated?
Do not administer w pegloticase, didanosine, azathioprine, mercatopurine
81
What is the MOA of probenecid?
probenecid Increase excretion of serum uric acid by inhibiting the reabsorption of uric acid at PCT
82
When would you use probenecid?
2nd line to replace XOI for chronic gout For undersecreters
83
What are side effects/adverse effects for probenecid?
``` Side Effects: n/v Dizziness HA Anorexia Dermatitis Gout exacerbations ``` Adverse: G6PD deficiency can have hemolytic anemia & aplastic anemia
84
What is the time frame response for probenecid?
Serum uric acid levels begin to decrease 2 weeks, up to 6mo full effect
85
What are cautions & contraindications w probenecid?
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
What is the MOA of pegloticase?
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
When would pegloticase be indicated?
Last line for chronic gout- dc all other antihyperuricemic agents Very expensive, IV q2 weeks
88
What are some side effects of pegloticase?
n/v | constipation
89
What is the time frame response for pegloticase?
reduction of uric acid in 1d-6mo
90
What are contraindications of pegloticase?
G6PD deficiency | BLACKBOX: hypersensitivity anaphylaxis
91
What are patient education points for pegloticase?
Start NSAIDS or colchicine to prophylaxis 1 week before start x6mo prevent flares Before infusion antihistamines & corticosteroid
92
What is the MOA for prednisone?
prednisone Methylprednisone Inhibits multiple inflammatory cytokines, produces multiple glucocorticoid & mineralcorticoid effects Decrease inflammation by suppressing migration of polymorphonuclear leukocytes
93
What are side effects/adverse effects of prednisone? What supplement would you ensure they take?
``` 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
What is the MOA of colcicine?
Colchicine NSAID Inhibit activation, degranulation, & migration of neutrophils to area of gout attack Decrease deposits of uric acid & phagocytosis
95
What are side effects of colchicine? When do you adjust dose? How long is therapy?
Diarrhea!!!!! pharyngolaryngeal pain, fatigue, HA Decrease dose for CrCl<30 & not repeat dose in 2 weeks Taken prophylactic <6mo therapy
96
What is time frame of response for colchicine?
Give 1st dose within 24h of sx onset Pain relief in 18-24h Inflammation effect 48h
97
What is contraindicated w colchicine?
CYP3A4 inhibitor | Renal & hepatic impairment
98
What would you educate a woman taking methotrexate of childbearing years?
must use contraception & inform when you intend to get pregnant
99
What meds can be give for tx of RA in pregnancy?
antimalarials, sulfasalazine, azathioprine, cyclosporine as mono or combo. Corticosteroids <15mg/d

Simmons NURP 423 Exam 2 (4 decks)

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