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PF3012 > Osteoarthritis and Gout > Flashcards

Osteoarthritis and Gout Flashcards

1
Q

Name 6 factors that increase risk of OA

A
  • female
  • BMI > 25
  • Age > 50
  • family history
  • previous injury
  • wear and tear through work or sport
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2
Q

Name a factor that decreases risk of OA

A
  • hormonal protective effect in women <40 years
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3
Q

What may be associated with a short period of early morning joint stiffness?

A

osteoarthritis

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4
Q

What are Heberden’s nodes on the hand symptomatic of?

A

osteoarthritis

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5
Q

What are the 3 main management options for OA

A
  • exercise
  • weight management
  • information and support
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6
Q

If pharmacological treatment for OA is required what should you offer?

A
  • lowest effective dose for shortest time period possible
  • offer a topical NSAID for knee OA
  • consider a topical NSAID for other OA affected joints
  • consider oral NSAID if topical are ineffective/unsuitable and offer gastroprotective treatment alongside
  • consider intra-articular corticosteroid injections for short term relief when other pharmacological treatments are ineffective
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7
Q

What pharmacological treatment should you not offer in OA

A
  • Paracetamol or weak opioids (unless for short term pain management)
  • glucosamine
  • strong opioids
  • intra-articular hyaluronan injections
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8
Q

do topical or oral NSAIDs have more side effects

A

oral

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9
Q

give 4 examples of topical NSAIDs

A

diclofenac
ibuprofen
ketoprofen
piroxicam

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10
Q

Name 5 classes which topical NSAIDs should not be used in

A

Asthmatics
Use on broken skin
Pregnant or breastfeeding women
Children under 12
People allergic to aspirin, ibuprofen or other NSAIDs

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11
Q

What is the side effect of topical ketoprofen?

A

Increases risk of photosensitisation

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12
Q

Do COX-1 or COX-2 have fewer GI side effects

A

COX-2

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13
Q

Which NSAID has the best side effect profile

A

Naproxen

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14
Q

How does diclofenac compare to naproxen

A

Diclofenac has similar efficacy but increased CV risk

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15
Q

How does ibuprofen compare to Naproxen

A

Good side effect profile, less efficacious than Naproxen

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16
Q

How does indomethacin compare to Naproxen

A

Indomethacin is more efficacious than Naproxen, but it has higher incidence of GI side effects

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17
Q

Name 5 COX-2 selective NSAIDS

A

Diclofenac
Etodolac
Celecoxib
Piroxicam
Meloxicam

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18
Q

Contraindications of Diclofenac

A

Heart failure
IHD
PAD
Cerebrovascular disease
Patients with significant risk factors (hypertension, hyperlipidaemia, diabetes, smoking) should only be treated after careful consideration

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19
Q

What is the EMA warning for Diclofenac?

A

Increased risk of arterial thrombotic events particularly at high doses (150mg) and long-term use

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20
Q

What does GRAB stand for in terms of NSAID side effects

A

G - gastrointestinal
R - renal
A - asthma
B - blood

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21
Q

How do NSAIDs cause renal side effects?

A

Na+ and water retention may occur
Renal function may deteriorate
Risk of HF and decompensation
Increased risk if taking diuretic

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22
Q

List 7 types of people who shouldn’t take NSAIDs

A
  • Asthmatics
  • Elderly patients more prone to side effects
  • Allergies to aspirin or NSAIDs
  • People with CHD or renal impairment
  • People with stomach ulcers
  • People taking similar medication on Rx
  • Pregnancy, especially third trimester
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23
Q

Increased risk factors for AIA

A
  • female
  • middle aged
  • severe asthma accompanied by chronic nasal congestion and profuse rhinorrhoea
  • history of nasal polyps
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24
Q

Patient has Rx for aspirin for CVD. What OTC analgesia should be given?

A

Paracetamol
NEVER ASPIRIN
Avoid NSAID

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25
Q

When would the use of NSAIDs in elderly people be potentially inappropriate?

A
  • With warfarin or DOAC (risk of major GI bleed)
  • With concurrent antiplatelet and no PPI (risk of PUD)
  • with concurrent corticosteroid and no PPI (risk of PUD)
  • with history of PUD or GI bleed with no PPI or H2RA (risk of relapse) (does not include COX-2 selective NSAIDs)
  • in patients with eGFR < 50ml/min/m2 (risk of renal deterioration)
  • in severe hypertension/ severe CHF (risk of exacerbation)
  • for longer than 3 months treatment of OA where paracetamol has not been tried
  • for chronic treatment of gout, where XO inhibitors have not been tried
  • COX-2 selective in concurrent CVD (increased risk of MI and stroke)
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26
Q

What is the adult oral dose of aspirin?

A
  • 300-600mg 4-6 times daily
  • maximum of 3.6g per day
  • take with or after food
27
Q

Who shouldn’t take aspirin for pain?

A
  • children <16
  • people with bleeding disorders or haemophilia
  • history of GI bleed or GI ulcer
  • symptomatic heart failure
28
Q

Cautions with aspirin

A
  • Elderly patients
  • Rx for medication that increase bleeding risk
  • Asthma
  • Rx low dose aspirin for CV prevention
29
Q

Adverse effects of aspirin

A
  • bleeding disorders, haemorrhage
  • hypersensitivity reactions
  • GI upset
  • confusion
  • tinnitus
  • impaired hearing and vertigo
  • bronchospasm
30
Q

Interactions of aspirin

A
  • drugs that increase bleeding risk
  • methotrexate
  • thiazide diuretics
31
Q

Symptoms of overdose (aspirin has the potential for overdose)

A
  • sweating
  • vasodilation
  • hyperventilation
  • tinnitus
  • deafness
32
Q

What is the prevalence of AIA in adults with asthma?

A

10%

33
Q

What is the first step on the WHO analgesia ladder?

A

Paracetamol

34
Q

Pharmacokinetics of paracetamol

A

Rapidly and almost completely absorbed from GI tract
Peak plasma concentrations in 30-60 minutes

35
Q

max dose of paracetamol

A

4g in 24 hours
reduce in hepatic impairment

36
Q

name 3 routes of admin of paracetamol

A

po
pr
iv

37
Q

are chondroitin or glucosamine useful for OA?

A

No

38
Q

what is the rationale that chondroitin should technically be good for OA?

A

-chondroitin is a GAG (glycosaminoglycan) made of glucuronic acid and galactosamine
- found in cartilage of most mammals needed to make joint matrix structure

39
Q

what is the rationale that glucosamine should technically be good for OA?

A

glucosamine is required for the synthesis of mucopolysaccharides which are carbohydrates like compounds found in tendons, ligaments, cartilage and synovial fluid

40
Q

What about intra-articular injections for OA?

A

Intra-articular steroid injections may be used (although pain reduction usually only lasts a week or two)
intra-articular hyaluronan (hyaluronic acid) injections are not recommended.

41
Q

What surgery is recommended for OA

A
  • joint replacement for debilitating symptoms
  • arthroscopic (keyhole surgery) not recommended
  • anti-coagulant therapy post-op essential
42
Q

What is gout?

A

Gout is a form of inflammatory arthritis
Deposition of monosodium urate crystals in synovial fluid and joints

43
Q

What are risk factors for gout?

A
  • male
  • increasing age
44
Q

co-morbidities associated with gout

A
  • CVD (increased mortality)
  • CKD
  • diabetes
  • obesity
  • psoriasis
45
Q

Drugs implicated in causing gout

A
  • diuretics, ACEi, ARBs
  • pyrazinamide
  • ritonavir
  • ciclosporin, tacrolimus
  • beta-blockers
    (lead exposure)
46
Q

What foods can cause gout

A
  • Purine rich food (red meat, sea food)
  • Alcohol
  • Sugar sweetened beverages
47
Q

What is first line treatment for acute flare up of gout

A

NSAIDs
- use for short period (1-2 weeks)

48
Q

What is second line treatment for acute flare up of gout if NSAIDs are C/I?

A

Corticosteroids
- Prednisolone po 30-35mg daily for 3-5 days then taper

Colchicine
- Give within 12 hours of flare up
- Loading dose of 1mg, followed by 0.5mg one hour later
- 0.5mg every 8 hours (bd), max 6mg in 3 days

49
Q

Adverse effects of colchicine

A

Diarrhea
Nausea
Vomiting
Abdominal pain
Blood disorders

50
Q

Interactions of colchicine

A

CYP, PGP

51
Q

What is canakinumab?

A
  • MAb used for acute gout flares
  • IL-1 inhibitor
  • Used when there are >3 flare ups per year and other treatments are ineffective
  • Risk of immunosuppression and infection
52
Q

What is the target serum urate level?

A
  • 360 micromoles/L
  • 300micromoles/L for patients with severe gout symptoms
53
Q

What is ULT

A
  • Urate lowering therapy (prevention)
  • Start >2 weeks after flare up
  • Start at low dose and titrate upwards
  • Monitor serum urate levels monthly during titration and 6 monthly once stable
54
Q

Name 2 xanthine oxidase inhibitors

A

Allopurinol (first line)
Febuxostat (Adenuric)
both can have hypersensitivity reactions

55
Q

What is the dose of Allopurinol?

A

100mg as a starting dose
Titrate up to 900mg daily in divided doses

56
Q

Instructions for taking allopurinol

A

Take with or after food
Increase fluid intake

57
Q

Cautions for allopurinol

A

Hepatic, renal impairment

58
Q

Allopurinol interactions

A
  • Amoxicillin
  • Ampicillin
  • Azathioprine
  • ACEi
  • Ciclosporin
  • Diuretics
  • Theophylline
  • Warfarin
59
Q

Febuxostat dosage

A

80mg od to start
Can increase to 120mg daily after 2-4 weeks

60
Q

Cautions with Febuxostat

A

IHD
heart failure
monitor liver function too

61
Q

Interactions with Febuxostat

A

Mercaptopurine
Azathioprine

62
Q

Name 3 uricosurics

A
  • Lesinurad
  • Probenecid
  • Sulfinpyrazone
63
Q

MOA of Uricosurics

A

Inhibit renal tubule reabsorption of uric acid

64
Q

Patient counselling for gout

A
  • diet
  • weight loss and exercise
  • low fat dairy products
  • importance of adherence to ULT (long term)

PF3012 (10 decks)

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