peter ingelman Flashcards
1
Q
what is RA?
A
chronic inflammatory progressive disease caused by production of autoantibodies which attack the cells lining small joints
2
Q
symptoms of RA
A
- pain
- swelling
- joint deformity
- joint swelling
- stiffness
3
Q
when are symptoms of RA worse?
A
in morning or after a period of inactivity
4
Q
what are flare ups?
A
period of time where symptoms of RA are worse
5
Q
how can RA be detected from blood samples?
A
- inc WBC (bc inflammatory)
- inc ESR (AB’s can bind to RBC hence drop to bottom, sediment, of tube faster)
- anaemia
- rheumatoid factor (AB’s for IgG)
6
Q
risk factors for RA
A
Age --> peak age now 65-75 years Gender --> premenopausal f>m, post m=f Post-partum Stress Genetic Smoking
7
Q
how does movement affect RA?
A
- improves on movement but worse in morning
8
Q
first line treatment for RA according to NICE is …
A
DMARD + glucocorticoid
9
Q
why is a glucocorticoid used alongside a DMARD?
A
as bridging therapy.
- used short term to improve symptoms whilst waiting for DMARD to kick in
10
Q
what DMARDS can be considered for initial treatment of RA?
A
mtx, sulfasalazine, leflunomide (with dose escalated as needed)
- hydroxychloroquine if mild or palindromic RA
11
Q
Indication and dose of prednisolone for RA
A
- Indication – reduction in rate of joint destruction in moderate to severe RA of less than 2 years’ duration.
- 30-40mg daily (usually 6-8 tablets all to be taken at once)
12
Q
side effects of prednisolone
A
- gastro-effects
- can affect breathing and cause bronchospasm
- anxiety
- abnormal behvaiour
- fatigue
13
Q
how to combat gastro effects of prednisolone in RA bridging therapy
A
PPI is recommended for use when on steroid due to gastro effects BUT as soon as steroid finished, PPI should be stopped
14
Q
use of NSAIDS and prednisolone
A
AVOID
- any NSAIDS, aspirin, anticoagulants and SSRI’s to be avoided with prednisolone
15
Q
when should a PPI be provided with a steroid?
A
when having repeating courses of the steroid
16
Q
treatment cessation for prednisolone
A
- if pt having for less than 3 weeks then can be abruptly stopped
- but peter seems to be relapsing patient and has had 40mg daily for more than 1 week hence needs to be ADJUSTED AND TITRATED OFF
17
Q
why is it necessary to wean off prednisolone?
A
to allow bodies renal system and adrenal glands to return to normal function as have suppressed the adrenocortical response
Abrupt withdrawal = hypotension, acute adrenal insufficiency
18
Q
cautions of prednisolone
A
- avoid if have pre-existing CVS issues as get water retention issues to heart
- avoid live virus vaccines
- CHF, diabetes, epilepsy
19
Q
counselling points for prednisolone
A
- single dose with food AM
- avoid contact with those with chickenpox, shingles, infections etc
- dont abruptly stop medication
- carry steroid card around
20
Q
comorbidities with RA
A
- hypertension
- MI
- stroke
- lung damage (hence peter smoking increases risk further)
21
Q
where does RA usually affect?
A
small joints of hands and feet usually bilaterally
22
Q
mtx indication and dose
A
indication: moderate to severe RA
DOSE: 7.5mg, max 20mg ONCE A WEEK by mouth after food (will be gradually increased)
23
Q
cautions of mtx
A
- diarrhoea –> signs of GI toxicity hence tretament must be stopped
- liver issues –> discontinue if an issue and abnormalities should return to normal in 2 weeks, start over again
- pulmonary toxicity (for those w RA) –> seek medical attention if dyspnoea, cough or fever
24
Q
what should be immediately reported when on mtx?
A
- blood disorder features (sore throat, bruising, mouth ulcers)
- liver toxicity (n+v, dark urine, ab discomfort)
- respiratory effects (SOB)
25
side effects of mtx
- anaemia
- drowsiness
- fatigue
- GI discomfort
- n+v (dont take another dose if v within a few hours of taking)
26
monitoring on mtx
- full blood count and lft's evert 1-2 weeks until therapy stabilised then 2-3 months
- report all signs of infection esp sore throat
- FBC, LFT's, U+E done before treatment also
27
why is folic acid also given?
mtx is a DHFR inhibitor hence folic acid is given to combat some side effects and replenish folate stores of body
28
when should folic acid be taken when on mtx?
on a different day to mtx, 5mg once a week
| can affect the absorption of mtx
29
missed dose of mtx
take as soon as remember or day after
| - if remember 3 or more days late then don't take, take next dose at right time instead
30
lifestyle advice for mtx
- try avoid unpasteurised milks and soft cheeses
- suitable contraception as teratogenic and wait 3 months after treatment finished to conceive
- no breastfeeding
- no self medicating with IBU or ASPIRIN
31
shared care agreement for mtx
- an amber med regime hence started in secondary care and need agreement with GP to continue
- patient can readily access their meds through GP
32
what is a shared care agreement?
outlines suggested ways which the responsibilities for managing prescribing of drug can be shared between specialist and GP
33
risks of mtx prescribed daily?
Daily dosing of methotrexate can increase likelihood of overdosing, and therefore, adverse side effects including death.
34
measures put in place to reduce risk of mtx OD?
- prescribing mtx in 2.5mg doses
- phasing out loose bottles and using blister packs
- carrying mtx cards
35
peter sounds underweight - what are actions would be appropriate to take?
- refer to dietician
- check renal function as renal function declines as weight does
- adjust any medication doses according to weight (+ renal function)
36
what is a COPD exacerbation?
a worsening or flare up of COPD symptoms. have narrowing and mucus build up caused by swelling/inflammation of airways
37
infective COPD exacerbation is....
when exacerbation is caused by bacteria or virus. yellowy/green sputum or just a sputum production
38
non-infective COPD exacerbation is ....
when exacerbation is caused by pollutants or irritants or allergens from the environment
39
symptoms of COPD exacerbation
- coloured sputum
- harder to do day-to-day activities
- cough increasing in severity or frequency
- fatigue
- high CO2 levels (trouble sleeping, headache when wake up, confused)
40
medications for infective and non-infective COPD
infective: amoxicillin, doxycyclin (pen allergy)
| non-infcetive: oral prednisolone (?) and o2 therapy
41
peter is on mtx during his exacerbation. what should be done?
stop the mtx for a few weeks as infective copd. infections can kill whilst RA pain for a few weeks wont kill and can be managed
42
issues with elderly taking PPI's
- can cause C.diff infections when long term used
| - affects bones negatively also
43
ideal:
- pulse
- resp rate
- 02 saturation
- pulse = 60-100
- resp rate = 12-16
- o2 saturation = 95-100% (88-92% in COPD patients)
44
issues that may arise for people when administering inhaler
- have bad inhaler technique hence med not reaching lungs well enough
- in peters case, has ra SO MIGHT NOT BE ABLE TO SQEEZE THE inhaler properly
45
patient care interventions when using inhalers (salbutamol, tiotropium and fostair)
- can check inhaler technique and see if spot anything concerning, check in device could be used for this
- spirometery test to see if needs smth else
- reduce inhaler burder with 2 in 1 med --> trimbow
- spacer if struggling with technique
- haleraid if struggling to press the inhaler
46
how can peter effectively deliver eye drops into his eyes?
- ask someone to administer for him (like daughter)
- compliance aids like auto-squeeze device, auto-drop device, opticare
- counsel on how to use eye drops too
47
what is ventolin?
salbutamol, a b2 adrenoreceptor agonist for asthma
48
what is tiotropium?
COPD maintenance, a LAMA
49
what is FEV1 and FVC?
FEV1 = forced expiratory volume, how much air can breathe out in forced breath
FVC = forced vital capacity, total lung capacity baso, how much air can breath out of lungs fully
50
what do you expect to see in asthma or COPD pt in respects to FVC/FEV1?
Lower readings than healthy
51
fev1/fvc ratio ideal percentages
should be 70% and 65% in pt's older than 65
- peter had 59% --> indicates more severe lung abnormality, moderately severe COPD
- inhalers need to be checked (technique and suitability)
52
latanoprost indication and dose
for glaucoma, one drop in affected eyes (both for peter) once a day, at night
53
latanoprost counselling points
- possible change in eye colour as inc in brown pigment can occur
- may get change sin eyelash hair (frequency, thickness etc)
- avoid contact with skin too regularly as can cause hyperpigmentation
54
vaccinations for peter (immunocompromised, COPD, old)
- should have flu, pneumococcal and covid vaccines
- on mtx hence immunocompromised, immune system not as good at defending itself atm
- also has COPD so higher chances of developing pneumonia
55
why is it important for peter to also get the pneumococcal vaccine specifically?
COPD is a risk factor for pneumonia
- weakens the respiratory and immune system and puts patients at a higher risk of respiratory failure + inc chances of pneumonia
- mucosal surface of a COPD patients lungs is constantly exposed to pathogens and changes to the microbiome can inc presence of pneumonia causing pathogens
56
bisphosphonates mechanism of action and indication for peter
work by slowing rate of bone growth and dissolution hence reducing rate of bone turnover
- used in peter for treatment of osteoporosis in men with high chance of fractures
57
bisphosphonates counselling points
- take first thing in morning (empty stomach so goes out of stomach quicker too), before breakfast with glass of water ensuring sat up straight for 30-60 minutes afterwards also
- if take at any other time of day, avoid food 2 hours before and after, especially calcium or iron containing foods
- DONT TAKE BEFORE BED OR SLEEPING
- report any ear pain or discharge
- maintain good oral hygiene
58
why is counselling of bisphosphonates so important?
corrosive so if not taken correctly may cause oesophageal burns (dont want reflux either) hence upright and loads of water to wash it down
59
peter has oral candidiasis, why could this be?
- dentures(?)
- is taking fostair (beclometasone and formetorol) --> LABA and ICS
- ICS can cause oral candidasis when not washed properly
60
how did they treat oral thrush in peters case and what were the issues?
- nystatin
- was hugely OD'ed, 100mL instead of 1mL
- could've got SE's like n+v, dia, gi discomfort
61
why is an ABG (arteriole blood gases) test used?
to measure the acidity and levels of o2 and co2 in the blood to determine how well o2 is moved to the lungs and co2 out of the blood
Also a lot quicker to do and gives info about the oxygenated blood
62
type 1 respiratory failure is...
when have damage to lung tissue resulting in inadequate oxygenation of blood but excretion of co2 is fine (low/normal co2 levels)
63
type 2 respiratory failure is ...
when have decreased alveolar ventilation (low o2) hence excretion of co2 is compromised, can lead to respiratory acidosis
- COMMON IN COPD PATIENTS
64
why do COPD patients have a O2 sat target of 88-92% not 95-100%?
pt's with copd have learned to compensate for the reduced amt of oxygenated haemoglobin hence if pump full of O2 to 95-100% target, will have too much and get high levels of co2 (respiratory acidosis) --> adding more o2 hinders the removal of co2
peter is also a smoker so has high levels of co poisoning hence might not even have rbc for good/high o2 levels
65
is O2 supply at home a good idea for peter? Why/why not?
NOT a good idea:
- o2 is flammable so anything lit around it goes boom (cannula needs to be removed and o2 turned OFF)
- also needs to be on o2 for 15 hr/day but peter smokes 20+/day hence wont be on o2 for long enough time
- storage is very particular (upright in safe place)
- therapy is expensive
66
instead of o2 therapy for peter what should be encouraged?
smoking cessation!
67
mtx for RA not sufficient for peter, whats next?
additional DMARD alongside mtx and folic acid
- leflunomide, sulfasalazine or hydroxychloroquine
- think about cost, what fits in best with pt lifestyle, interactions
68
when should the ideal body weight calculation be used?
on OVERWEIGHT PATIENTS ONLY
69
lifestyle advice for RA
- warm, dry environments
- heated houses
- healthy lifestyle
- gentle exercises (swimming, non-weight bearing and helps pain overtime)
70
is it beneficial for peter to use trimbow rather than 3 sep inhalers?
Y - cheaper to supply than 3 sep inhalers
Y - only has to take one inhaler so fewer devices and medicine burden (Can help compliance)
N - can't reduce dose of one medication, dose of all are reduced
N - want dose alteration in winter to higher as harder to breath but this is hard to do
71
what is Orthopnoea?
sensation of breathlessness relieved by sitting up or standing
usually SOB occurs when lying flat
72
what is Paroxysmal nocturnal dyspnoea?
sensation / having SOB that wakes pt up after a few hours of sleep and usually relieved in upright position
73
why is IV K+ not stored on most wards now (or in CD cupboard)?
if too much K+ given IV causes change in membrane polarisation which causes contraction of all muscles
- given on death row
- calc must be 2x/3x checked over!
74
what is the CURB-65 used for?
to assess severity of pneumonia. if have a score over 3 then need to be hospitalised
75
what is an NG tube?
(nasogastric tube) tube which bypasses throat and oesophagus so those who struggle to swallow can have easier medication administration
76
which medications cant be taken down an NG tube?
- enteric coated
- modified release
- suspensions (Can be sticky and stick to tube)
77
are bisphosphonates fine to go down NG tube?
yes!
| - corrosive so if we can bypass oesophagus and go to stomach ASAP works well
78
AB's given in community acquired pneumonia?
oral: amox, clarith or doxy
| but peter given co-amox but oen allegery hence best for him is levofloxacin
79
what is anaerobic cover and what medication is given for this?
metronidazole (loads of water, makes u feel shit also).
- have fluid build up in lungs in CAP
- good env for anaerobic bact to thrive
- so metronidazole given to kill those bacteria
80
why would lorazepam not be suitable for peter?
- hes elderly and benzo's in elderly can cause falls
| - also has respiratory issues so can cause resp depression
81
issues with family member ringing ward about a patient?
confidentiality, cant really tell them anything.
- if have consent from pateint then is fine to talk unless lacks capacity then can override patients choices
- if are next of kin then again fine to talk or go to next of kin to see if fine to talk to the family member
- try ask questions about the patient if need proof of identity
- can say general things like "had a good night sleep"
- family member may have enduring power of attourney in which case when pt lacks capacity then person y makes choices but needs to be signed and sorted way beforehand
82
final choice of medication for RA?
biologic
83
criteria for giving a biologic?
having had tried 2+ DMARDs with little symptomatic control and DAS28 of moderate atleast
84
why are biologics the last line of treatment in RA?
very expensive and need to be stringently used in line with guidance
- can get biosimilars tho
85
pre-screening with infliximab
for TB or any other life threatening infections (sepsis, pneumonia etc)
86
hydromol intesive indication and dose
dry skin and has anti itch properties, apply BD
87
issues with smokers using emollients
- emollients are flammable so easily can catch on fire when lighting cig
- also if emollient all over bed sheets then bed sheets also v flammable
88
are nebulisers better for drug delivery in COPD patients?
No evidence of this
- can buy nebuliser if want but still need Dr's prescription to get medication form changed to nebules
- dr can easily refuse
- consultant might find nebuliser nec at home in some cases (elderly, high treatment doseS needed)
89
peter is on 3 inhalers. which does trimbow replace?
tiotropium and fostair so peter only needs salbutamol separately now
90
issues with tiotropium DPI
- requires fair amount of dexterity to insert capsule into the inhaler
- need to take a deep breath to take the powder but peter frequently suffers from SOB
91
what are the risks of co-administering incompatible medications?
- formation of toxic metabolites
- precipitation
- drug degredation (more than 10% is an issue)
92
in peters case, could cefuroxime, metronidazole and clarithromycin be coadministered down the same IV?
NO
- cef and clarith are incompatible
- interactions between met and cef
- replace cefuroxime for levofloxacin
93
who can request and recieve info about a pt over the phone?
- hcp involved in care
- law enforcement if required by law
- fam/friends with consent from pt
- designated next of kin
94
can HCP overrule the decision of the person with power of attorney?
YES IF the decision isnt in the pt's bets interest
95
using nebuliser at home
- mouth piece needs to be well fitted to prevent anyone else breathing in the vapour
- needs to be regularly cleaned also as well as some parts being replaced every few months
96
correlation between RA and OA
pt's with RA more likely to develop OA also so vitamin D and ca supplements super important
97
inflammation in smokers with COPD
present in all smokers lungs and amplified in COPD leading to tissue destruction and disruption of the lungs repair mechanisms
98
what should COPD smokers do?
STOP SMOKING
- if not possible then e-cigs (Cant recommend as little safety info but studies shown they've helped)
- explore reasons WHY peter doesn't want to stop smoking
99
indication of carbocisteine
to reduce mucus viscosity to make it easier to cough up
100
suboptimal COPD care: patient non-compliance
- polypharmacy
- cant use the device
- lack of symptoms so might think dont need to use it
- lack of contact and positive reinforcement between HCP and pt
- patients altering the med dose etc themselves
101
suboptimal COPD care: physician non-compliance
tend to stick with experience of colleague advice rather than guidelines
102
suboptimal COPD care: underdiagosis
- viewed as sign of ageing
- mistaken for asthma
- failure to interpret spirometry results right
- failure to perform spirometry results correctly
103
why is a PPI (omep, lans) given with prednisolone?
- prednisolone interferes with the mucus prod of stomach
- musus protects the stomach
- less mucus hence acid can cause ulcers
- ppi to stop too much acid which can lead to stomach ulcers
104
how to know when to switch from IV to oral medications again
```
COMS criteria
C - clinical improvement
O - oral route not compromised (dont vomit too much, malabsorption is nilch)
M - markers showing a trend to usual
S - specific indication
```
105
which risk factors does peter exhibit for getting fractures?
- smoking
- RA
- drinking
- corticosteroid use
- immobility (Can barely get up the stairs)
106
vitamin d, Ca2+ and bisphosponates
vit d and ca2+ help with osteoporosis HOWEVER shouldnt be taken 2hours before or after a bisphosphonate tablet
107
COPD exacerbation inhalers used
1. SAMA (ipratropium) and SABA (Salbutamol)
not effective enough then
2. LABA (formetorol, salmeterol) and LAMA (tiotropium) added on (but SAMA stopped when LAMA added)
3. if have 2 moderate exacerbations a year an ICS (beclomethasone, fluticasone) added
108
moderate and severe exacerbations of COPD require what treatment?
```
moderate = systemic corticosteroids/AB's
severe = hospitalisation
```
