MUSCULOSKELETAL SYSTEM

Question 1

WHAT IS RHEUMATOID ARTHRITIS?

Answer 1

Chronic systemic inflammatory disease affecting joint synovial membrane

Question 2

SYNOVITIS PRESENTS AS..?

Answer 2

PAIN and STIFNESS- worsens with rest/inactivity/heat in joints

Question 3

SYMPTOMS OF RHEUMATOID ARTHRITIS?

Answer 3

NODULES
SWELLING
TENDERNESS
MALAISE
FATIGUE
FEVER
WEIGHT LOSS

Question 4

RHEUMATOID ARTHRITIS- TREATMENT

NON-DRUG THERAPY?

Answer 4

PHYSIOTHERAPY
EXERCISE
RELAXATION
STRESS MANAGEMENT

Question 5

RHEUMATOID ARTHRITIS- TREATMENT

DMARD DRUG THERAPY
1st LINE?
2nd LINE?

rapid suppression needed?

Answer 5

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

Question 6

RHEUMATOID ARTHRITIS

PAIN RELIEF?
GASTRO-PROTECTION

Taking aspirin already?

Answer 6

PAIN RELIEF? NSAIDs calm
GASTRO-PROTECTION? PPI

Taking aspirin already? Consider other pain relief before NSAID, bleeding risk

Question 7

METHOTREXATE & ASPIRIN/IBUPROFEN?

Answer 7

OTC BIG NO, but prescribed? Yeah calm

Question 8

METHOTREXATE KEY COUNSELLING?

Answer 8

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

Question 9

METHOTREXATE- SIDE EFFECTS?

Answer 9

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

Question 10

METHOTREXATE TOXICITY ANTIDOTE?

Answer 10

FOLINIC ACID (calcium folinate)

Question 11

METHOTREXATE

MONITORING?

SCREENING?

Answer 11

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

Question 12

METHOTREXATE- INTERACTIONS?

Answer 12

NEPHROTOXIC DRUGS- MTX reduces renal function, NO OTC ibuprofen
ANTI-FOLATES- Trimethoprim/Phenytoin
HEPATOTOXIC DRUGS- Rifampicin/Antifungals
OMEPRAZOLE/ESOMEPRAZOLE- reduces clearance+increases toxicity

Question 13

What is HYPERURICAEMIA/GOUT?

Answer 13

Raised uric acid conc. in blood (hyperuricaemia)+ deposition of urate crystals in joints and other tissues

Question 14

CAUSES OF HYPERURICAEMIA/GOUT?

Answer 14

DIET (high salt intake)
Bendroflumethiazide
Chemo

Question 15

GOUT- ACUTE TREAMENT?

Answer 15

COLCHICINE 500mcg BD-QDS, max. 3 days, DO NOT REPEAT COURSE WITHIN 3 DAYS
OR
High dose NSAID+PPI (excluding aspirin)

Question 16

GOUT PATIENT, TAKING DIURETICS?

Answer 16

AVOID NSAIDs, induces fluid retention, so colchicine instead!

Question 17

ALTERNATIVE ACUTE GOUT TREATMENT?

Answer 17

Short course oral corticosteroid
OR
IM injection of corticosteroid
canakinumab (gouty arthritis, >/=3 attacks/year)

Question 18

GOUT- CHRONIC TREATMENT
Only offered in?

1st LINE?
2nd LINE?

Acute attack during treatment?

Answer 18

Only offered in? >/=2 acute attacks of gout past year

1st LINE? Allopurinol
2nd LINE? Febuxostat

Acute attack during treatment? TAKE BOTH

Question 19

ALLOPURINOL

Side-effect?

Interaction?

Answer 19

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

Question 20

NOCTURNAL LEG CRAMPS

Treatment?

Toxicity risk, so only treat if..?

Trial for..?

Stop treatment every..?

Answer 20

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

Question 21

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?

Answer 21

Contraindicated in? asthmatic patients (bronchospasm)

Question 22

PAIN & INFLAMMATION (NSAIDs)

2 MAIN SIDE-EFFECTS OF NSAIDs?

Answer 22

Gastrointestinal

Cardiovascular

Question 23

PAIN & INFLAMMATION (NSAIDs)
NSAIDS- GI side-effects
HIGH to LOWEST risk
HIGH?
MEDIUM?
LOW?
LOWEST?

Answer 23

HIGH? piroxicam/ketoprofen/ketorolac
MEDIUM? indometacin/diclofenac/naproxen
LOW? ibuprofen
LOWEST? COX-2 selective inhibitors

Question 24

PAIN & INFLAMMATION (NSAIDs)
NSAIDs- CVD side-effects
HIGH?
LOW?

Answer 24

HIGH? COX-2 selective inhibitors/ibuprofen 2.4g/diclofenac

LOW? naproxen/ibuprofen 1.2g

Question 25

COX-2 Selective Inhibitors Examples?

Answer 25

Celecoxib | Etoricoxib

Question 26

PAIN & INFLAMMATION (NSAIDs) What increases GI bleed risk/cross-sensitivity? Use a stomach protectant? AVOID IN?

Answer 26

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

Question 27

NSAIDS INTERACTIONS?

Answer 27

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

Question 28

Answer 28

Question 29

Hyperuricaemia treatment?

Answer 29

Rasburicase

Question 30

Answer 30

Question 31

atorvastatin causes?

Answer 31

hyperglycaemia

Question 32

GLIPTINS, RTI INFECTION?

Answer 32

Yh, interstitial lung disease

Question 33

dose for allopruionol and colchicije and ibuprofen in GOUT

Answer 33

allo 100mg mild 300-600mg moderate severe

Question 34

GOUT DOSING?

Answer 34

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)

Question 35

IBANDRONIC ACID OSTEOPOROSIS?

Answer 35

150mg monthly

Question 36

GOUT Patient on diuretic+antihypertensive, treatment?

Answer 36

COLCHICINE Avoid NSAID cos hyperkalaemia/renal impairment L

Question 37

GOUT DOSING?

Answer 37

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)

Question 38

drug to avoid in gout?

Answer 38

bendroflumethiazide