Muskuloskeletal Flashcards
What are the symptoms of rheumatoid arthiritis?
Swollen, hot, stiff and motionless joints
What are the risks of DMARDs
Blood dyscrasia
- high risk of infections
Which DMARD causes orange tears and urine?
Sulfasalazine
What are the risks of cyclophosphamide?
Haemorrhagic cystitis and permanent male sterility
What are the risks of leflunomide?
Hepatotoxicity
Effective contraception after treatment - men for 3 months and women for 2 years
What are the risks of chloroquine?
Retinopathy - screen for ocular toxicity
What is the treatment pathway for arthiritis?
1st line: conventional DMARD
- oral methotrexate, lefluonmide, sulfasalazine
2nd line: combination of 2 conventional DMARDs
3rd line: cytokine modulators
DMARDs can take 2-3 months to reduce inflammation therefore, corticosteroids (or sometimes NSAIDs) can be used for this short-term and during flare-ups
How do you treat severe active RA?
methotrexate + rituximab
How is methotrexate taken for autoimmune conditions?
Once weekly on a specific day
What are the MHRA warnings for methotrexate?
overdose of methotrexate for non-cancer treatments
- only one strength tablet is prescribed
- decide on a day of the week to take
What is the missed dose advise for methotrexate?
If the missed dose is >3 days = continue with next schedule dose
If day or two later - take as soon as they remember
If vomit within a few hours of taking - do NOT take a second dose
What if the purpose of prescribing folic acid with methotreaxte?
Help reduce anti-folate side effects of methotrexate e.g. mucositis and may also prevent hepatotoxicity
When should folic acid be taken?
DO NOT take on the same day as methotrexate because it will reduce the therapeutic effects of methotrexate and antagonise it
Possible regimens:
- 5mg once weekly, different day to methotrexate
- 1 or 5mg daily except on the day methotrexate is taken
What are the side effects of methotrexate?
- Immunosuppression - can occur if take daily instead of weekly
- Blood disorders e.g. neutropenia and low red blood cells which can lead to anaemia and thrombocytopenia
(low white blood cell weakens immune system = increases risk of infections) - Nephrotoxicity (monitor renal function)
- Hepatotoxicity: monitor LFTs, report liver disorders
C/I ascites - Pulmonary toxicity: report respiratory effects
C/I significant pleural effusion - GI toxicity: stop if stomatitis or diarrhoea
- Phototoxicity: sunburns and blisters
What are the contraindications of methotrexate?
Active infections
Immunodeficiency syndromes e.g. HIV
What counselling do you need to provide to a patient taking methotreaxte?
Fever
Sore throat
Mouth ulcers
Bruising
Bleeding
What can be used for acute methotrexate toxicity?
Folinic acid
Also prevents immunosuppression especially when used to treat cancer with high doses
How long after methotrexate must contraception continue?
6 months - men and women
- may be present in breastmilk, do not breastfeed
What drugs interact with methotrexate?
Blood disorder:
- Trimethoprim - both are anti-folate drugs and can cause bone marrow suppression = blood disorders
- Clozapine
- Phenytoin (anti-folate)
- Cytotoxic
- Immunosuppressants
Reduced renal clearance = methotrexate toxicity:
- NSAIDs (both nephrotoxic): avoid taking at the same time
- Penicillins
- PPI
Nephrotoxicity
- aminoglycosides
- Cephalosporin
- Ciclosporin
- Tacrolimus
- NSAIDs
Hepatotoxicity
- co-amoxiclav
- fluclox
- tetracyclines
- carbamazepine
- valporate
- fluconazole
- isoniazid
- sulfasalazine
What are the symptoms of oesteoarthiritis?
Stiff motionless joints
- usually weight-bearing joints
What is the treatment for oesteoarthiritis?
1st line: topical NSAID
- Oral NSAID
- Paracetamol or weak opioid
What are the symptoms of gout?
Sudden severe intense joint pain, swelling and purple-red shiny skin
Over time with frequent and severe attacks - tophi can form
Which drugs worsen or exacerbate gout?
Loop and thiazide diuretics
Cytotoxic drugs
Ciclosporin and tacrolimus
How is an acute gout attack treated?
NSAIDs - not aspirin
Colchicine - max dose 500mcg BD-QDS
- no repeat course in 3 days
Oral corticosteroid
How is the prevention of gout treated?
1st line allopurinol
Or
Febuxostat
Never start during attack
Can trigger an acute gout attack when started
If gout attack occurs during prevention - continue as normal and treat gout attack separately
What are the MHRA warnings for febuxostat
Hypersensitivity reactions - anaphylaxis or steven-johnsons syndrome
Cardiovascular disease
How is allopurinol taken?
With or just after food
What are the side effects of allopurinol?
Rash - stop if mild and reintroduce slowly
- stop if reoccurs
What are the interactions of allopurinol?
Azathioprine and mercaptopurine toxicity = reduce doses of these by 25-50%
Hypersensitivity with ACEi
Skin rash - penicillins
What is the uses of quinine?
Antimalarial drug
Nocturnal leg cramps
- only use for this if regular sleep disturbances
- failed non-pharmacological treatments
- frequent or very painful
What are the side effects of quinine?
Toxic in overdose
- convulsions, arrhythmias
Blindness, tinnitus
- C/I: tinnitus and optic neuritis
QT prolongation
- conduction abnormalities
- risk factors = hypokalaemia
What is baclofen used for?
Chronic severe spasticity e.g. in multiple sclerosis
- in palliative care
What is the side effects of baclofen?
Drowsiness
Muscular hypotonia
Avoid abrupt withdrawal - withdrawal symptoms
What are the side effects of NSAIDs?
Asthma and dyspnoea
NSAID hypersensitivity
- asthma attack, urticaria, rhinitis
Photosensitivity - topical
Nephrotoxicity - can cause AKI
Odema
Hypertension
Bleeding
Hyperkalaemia
Which NSAIDs cannot be given in any history of GI ulcer or bleeding even if it wasnt cause by an NSAID?
Ketoprofen
Ketorolac
Piroxicam
These have the highest risk of GI toxicity
What drugs interact with NSAIDs?
Nephtotoxicity
- aminoglycosides
- cephlosporin
- glycopeptide
- ciclosporin and tacrolimus
- methotrexate
Renal clearance = toxicity
- lithium
- methotrexate
Bleeding
- alcohol
- anticoagulants
- warfarin
- corticosteroids
- SSRI
- venlafaxine
Hyperkalaemia
- ACEi/ ARB
- ciclosporin and tacrolimus
- heparin
- potassium-sparing diuretics
- trimethoprim
Seizures
- quinolones
