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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
When would the use of NSAIDs in elderly people be potentially inappropriate?
- 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)
26
What is the adult oral dose of aspirin?
- 300-600mg 4-6 times daily - maximum of 3.6g per day - take with or after food
27
Who shouldn't take aspirin for pain?
- children <16 - people with bleeding disorders or haemophilia - history of GI bleed or GI ulcer - symptomatic heart failure
28
Cautions with aspirin
- Elderly patients - Rx for medication that increase bleeding risk - Asthma - Rx low dose aspirin for CV prevention
29
Adverse effects of aspirin
- bleeding disorders, haemorrhage - hypersensitivity reactions - GI upset - confusion - tinnitus - impaired hearing and vertigo - bronchospasm
30
Interactions of aspirin
- drugs that increase bleeding risk - methotrexate - thiazide diuretics
31
Symptoms of overdose (aspirin has the potential for overdose)
- sweating - vasodilation - hyperventilation - tinnitus - deafness
32
What is the prevalence of AIA in adults with asthma?
10%
33
What is the first step on the WHO analgesia ladder?
Paracetamol
34
Pharmacokinetics of paracetamol
Rapidly and almost completely absorbed from GI tract Peak plasma concentrations in 30-60 minutes
35
max dose of paracetamol
4g in 24 hours reduce in hepatic impairment
36
name 3 routes of admin of paracetamol
po pr iv
37
are chondroitin or glucosamine useful for OA?
No
38
what is the rationale that chondroitin should technically be good for OA?
-chondroitin is a GAG (glycosaminoglycan) made of glucuronic acid and galactosamine - found in cartilage of most mammals needed to make joint matrix structure
39
what is the rationale that glucosamine should technically be good for OA?
glucosamine is required for the synthesis of mucopolysaccharides which are carbohydrates like compounds found in tendons, ligaments, cartilage and synovial fluid
40
What about intra-articular injections for OA?
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
What surgery is recommended for OA
- joint replacement for debilitating symptoms - arthroscopic (keyhole surgery) not recommended - anti-coagulant therapy post-op essential
42
What is gout?
Gout is a form of inflammatory arthritis Deposition of monosodium urate crystals in synovial fluid and joints
43
What are risk factors for gout?
- male - increasing age
44
co-morbidities associated with gout
- CVD (increased mortality) - CKD - diabetes - obesity - psoriasis
45
Drugs implicated in causing gout
- diuretics, ACEi, ARBs - pyrazinamide - ritonavir - ciclosporin, tacrolimus - beta-blockers (lead exposure)
46
What foods can cause gout
- Purine rich food (red meat, sea food) - Alcohol - Sugar sweetened beverages
47
What is first line treatment for acute flare up of gout
NSAIDs - use for short period (1-2 weeks)
48
What is second line treatment for acute flare up of gout if NSAIDs are C/I?
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
Adverse effects of colchicine
Diarrhea Nausea Vomiting Abdominal pain Blood disorders
50
Interactions of colchicine
CYP, PGP
51
What is canakinumab?
- 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
What is the target serum urate level?
- 360 micromoles/L - 300micromoles/L for patients with severe gout symptoms
53
What is ULT
- 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
Name 2 xanthine oxidase inhibitors
Allopurinol (first line) Febuxostat (Adenuric) both can have hypersensitivity reactions
55
What is the dose of Allopurinol?
100mg as a starting dose Titrate up to 900mg daily in divided doses
56
Instructions for taking allopurinol
Take with or after food Increase fluid intake
57
Cautions for allopurinol
Hepatic, renal impairment
58
Allopurinol interactions
- Amoxicillin - Ampicillin - Azathioprine - ACEi - Ciclosporin - Diuretics - Theophylline - Warfarin
59
Febuxostat dosage
80mg od to start Can increase to 120mg daily after 2-4 weeks
60
Cautions with Febuxostat
IHD heart failure monitor liver function too
61
Interactions with Febuxostat
Mercaptopurine Azathioprine
62
Name 3 uricosurics
- Lesinurad - Probenecid - Sulfinpyrazone
63
MOA of Uricosurics
Inhibit renal tubule reabsorption of uric acid
64
Patient counselling for gout
- diet - weight loss and exercise - low fat dairy products - importance of adherence to ULT (long term)

PF3012 (10 decks)

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