MUSCULOSKELETAL SYSTEM Flashcards
WHAT IS RHEUMATOID ARTHRITIS?
Chronic systemic inflammatory disease affecting joint synovial membrane
SYNOVITIS PRESENTS AS..?
PAIN and STIFNESS- worsens with rest/inactivity/heat in joints
SYMPTOMS OF RHEUMATOID ARTHRITIS?
NODULES SWELLING TENDERNESS MALAISE FATIGUE FEVER WEIGHT LOSS
RHEUMATOID ARTHRITIS- TREATMENT
NON-DRUG THERAPY?
PHYSIOTHERAPY
EXERCISE
RELAXATION
STRESS MANAGEMENT
RHEUMATOID ARTHRITIS- TREATMENT
DMARD DRUG THERAPY
1st LINE?
2nd LINE?
rapid suppression needed?
DMARD DRUG THERAPY
1st LINE? Methotrexate/Leflunomide/Sulfasalazine (hydroxychloroquine in mild)
2nd LINE? MABs: Adalimumab/Etanercept/Infliximab/Tocilizumab/Baricitinib
rapid suppression needed? Bridge w/ corticosteroids
RHEUMATOID ARTHRITIS
PAIN RELIEF?
GASTRO-PROTECTION
Taking aspirin already?
PAIN RELIEF? NSAIDs calm
GASTRO-PROTECTION? PPI
Taking aspirin already? Consider other pain relief before NSAID, bleeding risk
METHOTREXATE & ASPIRIN/IBUPROFEN?
OTC BIG NO, but prescribed? Yeah calm
METHOTREXATE KEY COUNSELLING?
Take once weekly
Prescription+label- clear dose & frequency
Commonly prescribed w/ folic acid (different days)
IMMEDIATELY REPORT SIGNS OF: blood disorder/liver toxicity/respiratory effects
METHOTREXATE- SIDE EFFECTS?
BPLG
BLOOD DISORDERS- sore throat/bruising/mouth ulcers
LIVER - nausea/vomiting/abdominal discomfort/jaundice/dark urine/itchy skin
PULMONARY - SOB/coughing
G-I - stomatitis/diarrhoea
DARK URINE/ABDOMINAL DISCOMFORT SOB SORE THROAT BRUISING MOUTH ULCERS
METHOTREXATE TOXICITY ANTIDOTE?
FOLINIC ACID (calcium folinate)
METHOTREXATE
MONITORING?
SCREENING?
MONITORING? FBC+RENAL+LFT:
every 1-2 weeks till stable
every 2-3 months therafter
SCREENING? Pregnancy PRIOR to treatment
Antifolate- harmful to foetus growth
Use effective contraception during+6 months after treatment, both man & woman
METHOTREXATE- INTERACTIONS?
NEPHROTOXIC DRUGS- MTX reduces renal function, NO OTC ibuprofen
ANTI-FOLATES- Trimethoprim/Phenytoin
HEPATOTOXIC DRUGS- Rifampicin/Antifungals
OMEPRAZOLE/ESOMEPRAZOLE- reduces clearance+increases toxicity
What is HYPERURICAEMIA/GOUT?
Raised uric acid conc. in blood (hyperuricaemia)+ deposition of urate crystals in joints and other tissues
CAUSES OF HYPERURICAEMIA/GOUT?
DIET (high salt intake)
Bendroflumethiazide
Chemo
GOUT- ACUTE TREAMENT?
COLCHICINE 500mcg BD-QDS, max. 3 days, DO NOT REPEAT COURSE WITHIN 3 DAYS
OR
High dose NSAID+PPI (excluding aspirin)
GOUT PATIENT, TAKING DIURETICS?
AVOID NSAIDs, induces fluid retention, so colchicine instead!
ALTERNATIVE ACUTE GOUT TREATMENT?
Short course oral corticosteroid
OR
IM injection of corticosteroid
canakinumab (gouty arthritis, >/=3 attacks/year)
GOUT- CHRONIC TREATMENT
Only offered in?
1st LINE?
2nd LINE?
Acute attack during treatment?
Only offered in? >/=2 acute attacks of gout past year
1st LINE? Allopurinol
2nd LINE? Febuxostat
Acute attack during treatment? TAKE BOTH
ALLOPURINOL
Side-effect?
Interaction?
Side-effect? Hypersensitivity/rash (discontinue therapy; if rash mild re-introduce carefully but discontinue immediately if L again)
Interaction? Allopurinol+Azathioprine/Mercaptopruine
reduce dose of aza/merc
NOCTURNAL LEG CRAMPS
Treatment?
Toxicity risk, so only treat if..?
Trial for..?
Stop treatment every..?
Treatment? Quinine sulfate
Toxicity risk, so only treat if..? cramps disrupt sleep/painful/other treatments L QT PROLONGATION
Trial for..? 4 weeks, benefit? Continue
Stop treatment every..? 3 months+assess need for further treatment
PAIN & INFLAMMATION (NSAIDs)
NSAIDS- analgesics+anti-inflammatory- used in pain related to inflammation (e.g. rheumatoid arthritis, back pain and soft-tissue disorders)
Contraindicated in?
Contraindicated in? asthmatic patients (bronchospasm)
PAIN & INFLAMMATION (NSAIDs)
2 MAIN SIDE-EFFECTS OF NSAIDs?
Gastrointestinal
Cardiovascular
PAIN & INFLAMMATION (NSAIDs) NSAIDS- GI side-effects HIGH to LOWEST risk HIGH? MEDIUM? LOW? LOWEST?
HIGH? piroxicam/ketoprofen/ketorolac
MEDIUM? indometacin/diclofenac/naproxen
LOW? ibuprofen
LOWEST? COX-2 selective inhibitors
PAIN & INFLAMMATION (NSAIDs)
NSAIDs- CVD side-effects
HIGH?
LOW?
HIGH? COX-2 selective inhibitors/ibuprofen 2.4g/diclofenac
LOW? naproxen/ibuprofen 1.2g
COX-2 Selective Inhibitors Examples?
Celecoxib
Etoricoxib
PAIN & INFLAMMATION (NSAIDs)
What increases GI bleed risk/cross-sensitivity?
Use a stomach protectant?
AVOID IN?
What increases GI bleed risk/cross-sensitivity? Aspirin
Use a stomach protectant? PPI
AVOID IN?
Renal impairment- risk of fluid retention/further impairment
Pregnancy- caution in breastfeeding
ASTHMA
NSAIDS INTERACTIONS?
MTX/Lithium- reduces clearance
Cipro- seizures
Blood thinners/SSRIs/Corticosteroids- bleeding
Drugs causing hyperkalaemia, trimethoprim/ACEi/ARB/b-blocker- hyperkalaemia
Drugs causing renal failure- AKI
Hyperuricaemia treatment?
Rasburicase
atorvastatin causes?
hyperglycaemia
GLIPTINS, RTI INFECTION?
Yh, interstitial lung disease
dose for allopruionol and colchicije and ibuprofen in GOUT
allo 100mg mild
300-600mg moderate severe
GOUT DOSING?
Gout: Acute
1st Line: NSAIDs e.g. Diclofenac, Naproxen
Ibuprofen: initially 300-400mg TDS-QDS
Diclofenac: 75-150mg OD in 2-3 divided doses
Alt: Colchicine: max 500mcg BD-QDS max 6mg per course and do not repeat course in 3 days
Gout: Prevention
1st Line: Allopurinol: Initially 100mg OD
2nd Line: Feboxust
Alt: Sulfinpyrazone (initiation may precipitate an acute attack)
IBANDRONIC ACID OSTEOPOROSIS?
150mg monthly
GOUT
Patient on diuretic+antihypertensive, treatment?
COLCHICINE
Avoid NSAID cos hyperkalaemia/renal impairment L
GOUT DOSING?
Gout: Acute
1st Line: NSAIDs e.g. Diclofenac, Naproxen
Ibuprofen: initially 300-400mg TDS-QDS
Diclofenac: 75-150mg OD in 2-3 divided doses
Alt: Colchicine: max 500mcg BD-QDS max 6mg per course and do not repeat course in 3 days
Gout: Prevention
1st Line: Allopurinol: Initially 100mg OD
2nd Line: Feboxust
Alt: Sulfinpyrazone (initiation may precipitate an acute attack)
drug to avoid in gout?
bendroflumethiazide
