Musculoskeletal System

Question 1

Symptoms of Rheumatoid Arthritis (To distinguish from OA)

Answer 1

• Bilateral joints affected
• Morning pain/stiffness > 30 mins
• Starts in small joints in hands or feet

Question 2

First Line Treatment for RA

Answer 2

Non-Drug Therapy: Physio, stress management

Question 3

First Line Drug Treatment for RA

Answer 3

DMARDs (Methotrexate, leflunomide, sulfasalazine)

Question 4

Second Line Drug Treatment for RA

Answer 4

Monoclonal Antibodies - infliximab, adalimumab, tocilizumab

Question 5

Most Appropriate Pain relief for RA

Answer 5

NSAIDs (ibuprofen)
–> can’t be given OTC with methotrexate
–> monitor if given on prescription

Question 6

Monitoring for Methotrexate

Answer 6

FBC, Renal Function, LFTs
- every 1-2 weeks until stable
- then every 2-3 months

Rule out pregnancy

Question 7

Methotrexate Interactions

Answer 7

Nephrotoxic Drugs
Antifolates (trimethoprim)
Hepatotoxics (rifampicin)
Omeprazole (reduces clearance of mtx)

Question 8

What is gout?

Answer 8

Raised uric acid levels in the blood which leads to deposition of urate crystals in the joints

Question 9

What can cause gout?

Answer 9

High salt intake
Medications (bendroflumethiazide, chemo)

Question 10

Treatment for Acute Got

Answer 10

Colchicine (500mcg 2-4 times a day) for max 3 days.

Question 11

In what time frame can you not repeat a course of colchicine?

Answer 11

Do not repeat within 3 days

Question 12

Alternative Treatment for Colchicine

Answer 12

Short course of corticosteroids (oral or IM)

Question 13

When can treatment for chronic gout be offered?

Answer 13

If had two or more attacks in one year

Question 14

What is first line treatment for chronic gout?

Answer 14

Allopurinol

Question 15

What is second line treatment for chronic gout?

Answer 15

Febuxostat

Question 16

What should a patient with chronic gout do if they experience an acute attack?

Answer 16

Continue chronic treatment whilst treating the acute attack separately

Question 17

What is a common side effect with colchicine?

Answer 17

Diarrhoea

Question 18

What is a common side effect with allopurinol?

Answer 18

Rash (hypersensitivity)
- if pt gets rash then discontinue (if only mild, can restart carefully but discontinue again if rash reoccurs)

Question 19

Allopurinol Interactions

Answer 19

Azathioprine
Mercaptopurine
–> reduce dose of these if concomitant use

Question 20

Treatment for Nocturnal Leg Cramps

Answer 20

Quinine sulfate (only use if cramps regularly disrupt sleep, if very painful or other treatments fail)

Question 21

How often show quinine treatment for nocturnal leg cramps be reveiwed?

Answer 21

First trialled for 4 weeks
- Then reviewed every 3 months to assess benefit

Question 22

Contraindication of NSAIDs

Answer 22

asthma –> bronchospasms

Question 23

List the NSAIDs and their associated risk of GI side effects

Answer 23

Lowest risk - COX-2 Selective Inhibitors
Low - Ibuprofen
Medium - Indometacin, diclofenac, naproxen
High - Piroxicam, Ketoprofen, Ketorolac

Question 24

List the NSAIDs and their associated risk of CV side effects

Answer 24

Low risk - naproxen , ibuprofen 1.2mg

High risk - COX-2 Selective Inhibitors , ibuprofen 2.4g, diclofenac

Question 25

Contraindications of NSAIDs

Answer 25

Active bleeding/ulceration,
Previous NSAID-associated bleeding,
Recurrent GI ulceration,
Severe heart failure
History of hypersensitivity to aspirin

Question 26

NSAID Interactions

Answer 26

Methotrexate and lithium - reduces clearance

Ciprofloxacin - increases seizure risk

SSRIs, steorids, DOACs, carbocisteine

Hyperkalaemia causing drugs : Trimethoprim, heparins, ACE, Potassium-sparing diuretics, beta blockers

Nephrotoxic drugs