Pharm Rheum/MSK Flashcards
what do you use to treat acute musculoskeletal conditions
- RICE
- oral and topical analgesics
- acetaminophen, tNSAIDS, COX2
what do you use to treat osteoarthritis?
acetaminophen, tNAIDS, COX 2
how does acetaminophen decrease pain?
decreases CNS and spinal cord prostaglandin production
what is a example of a topical NSAID used to treat acute muskuloskeletal conditions
diclofenac (gel or patch)
what is the name of a local anesthetic used to treat acute musculoskeletal pain? what forms does it come in?
lidocaine
aerosol, cream, gel, spray, solution, transdermal patch
what are 4 counter irritants used to treat acute musculoskeletal pain?
- methyl salicylate (Ben Gay, Icy Hot)
- Methol (icy hot)
- Methyl nicotinate
- capsaicin
what are the 5 thing used to treat acute muscloskeletal conditions?
- RICE
- acetaminophen
- tNSAIDs
- local anesthetics
- counter irritants
what are the 8 possible treatments for osteoarthritis?
- exercise
- weight loss
- acetominophen
- tNSAIDS
- glucosamine (chronic pain ~6 weeks)
- tramadol (ultram, ryzolt) aka codeine and opoids
- intra-articular steroids, hyaluronic acid
what are the proinflammatory mediators associated with RA? (4)
TNF-alpha
IL-1
IL-6
IL-17
what are the anti-inflammatory mediators associated with RA? (2)
IL-4
IL-10
what do the drugs of RA target?
the inflammatory intermediates
what are the significant comorbidities seen with RA (4)
- cardiovascular disease
- infections
- malignancy
- osteoporosis
these comorbidities are lethal, so need to control them with other drugs
what are the treatment timing goals of RA? what do you treat with? what are the two treatment approaches?
DMARDS within 3 months of diagnosis
- step up therapy
- step down therapy (preferred)
what do you need to be cautious of in the treatment of RA?
pregnancy
what 3 main things does RA stimulate?
- t-lymphocytes
- cytokine release
- B-lymphocytes
when T-lymphocytes are activated in RA, this causes what four things?
- macrophages to release cytokines
- activation of osteoclasts
- activation of matrix metaloproteases that degrades connective tissue
- B cells to make antibodies
what does the activation of B cells cause in RA?
antibodies and increase in RF and CRP
what are the four major groups of drugs that can be used to treat or relieve pain of RA?
MEDS THAT RELIEVE SYMPTOMS
1. tNSAIDS, COX2
MEDS THAT REDUCE PROGRESSION AND PAIN
- glucocorticoids: global anti-inflammatory/immune suppression
- non-biologic DMARDS
- biologic DMARDS
what is the pathophys of gout?
uric acid crystals in joint spaces leads to inflammation and pain, increased uric acid crystals
what medications can you use to treat gout? (4)
- NSAIDS: acute episodes and prophylaxsis
- colchicine
- corticosteroids: acute joint injection or systemic (IM or PO)
- antihyperuricemic prophylaxis ( 3 drugs)
what are the three antihyperuricemic prophylaxis drugs? (3) what do they do?
- allopurinal- reduces uric acid production
- febuxostat- reduces uric acid production
- probenicid- uricosuric aka increases excretion of uric acid by preventing tubular reabsorption
what is a caution of using probenicid in patients for gout?
increases uric acid excretion by preventing re-absorption, but in the processes increases risk for kidney stones
therefore, don’t use in patients with kidney stones!!
what is a characteristic of the COX-1 enzyme? where is it found?
constitutive
gastric mucosa, kidney, platelets
what is a characteristic of the COX-2 enzyme? where is it found?
inducible (by injury)
most tissues, injury induced
Cox-1 stimulates what two hormones?
prostaglandins
thromboxanes
prostaglandins do what two things in COX1?
protect gastric mucosa and dilate afferent artery of the glomerus
thromboxanes do what two things?
vasoconstriction
platelet aggregation
Cox1 stimulates what two hormones? what are those hormones functions?
- prostaglandins
- protect gastric mucosa
- dilate afferent artery of the glomerus - thromboxanes
- vasoconstriction
- platelet aggregation
COX-2 stimulates what two hormones?
- prostaglandins
2. prostacylcines
what do prostaglandins do when activated by COX-2 ?
pain, fever
what do prostcyclins do when activated by COX-2?
vasodilation and anti-platelet activity
Cox-2 enzyme activates which two hormones when induced? and what are their functions?
- prostaglandins
- fever
- pain - prostacyclins
- vasoconstriction
- anti-platelet activity
tNSAIDS block which enzymes and hormones?
BOTH COX1 and COX2
blocks all prostaglandin, thromboxane, and prostacycline hormones
the COX-2 selective inhibitors block what enzyme and hormones? what are the benefits to this? what are the negatives?
blocks COX-2
blocks prostaglandin produced by the COX-2 enzyme and prostcycline
this means increased gastric protection since the COX-1 prostaglandin isn’t inhibited but produces an imbalance of prostacylcin and thromboxane levels, where there is more thromboxane…..
…this can lead to CV disorders
what are 5 risk factors for adverse effects from NSAIDS
- Hx of peptic ulcer disease (PUD) or proton pump inhibitor (PPI)
- high dose NSAID
- use with anticoagulants, corticosteroids, multiple NSAIDS
- > 75 years old
- serious underlying disease like CKD, HF
what 3 drugs should you caution using when taking NSAIDS because it can set you up for increase risk for adverse effects?
- anticoagulants
- corticosteroids
- multiple NSAIDS
what can you expect to see pain relief from tNSAIDs?
pain relief within hours but full anti-inflammatory activity takes 2-3 weeks of continuous use
How does RA present?
-wrist, MCP, PIP joint involvement bilaterally
-
what is a DOC for RA? what else do you want to prescribe this with?
methotrexate plus NSAIDS
interesting: what do you also need to always prescribe when giving methotrexate for RA?
Leucovorin aka folic acid/B12
how is leucovorin (B12) dosed when it is given to a RA patient taking methotrexate?
5mg day after taking methotrexate, or 1 mg daily
interesting: what function to NSAIDS often take but what don’t they solve?
Bridge therapy, but don’t cure the disease, only the pain so make sure to treat the cause!
interesting: what is the standard of care for RA patients?
get on DMARD within 3 months
interesting: what pregnancy category is methotrexate so what do you need to monitor?
X!!!!!!! NOOOOO
monitor pregancy
interesting: what do you need to do before and after starting methotrexate?
need to ALWAYS get a xray before and after because it can cause pulmonary fibrosis so need to establish a baseline view
Case: if patient is unresponsive to methotrexate what should you do before switching meds? what is the max dose?
uptitrate this dose, max is 25 mg
What do you need to do for prednisone if the patient wants to stop the medication and it has been longer than two weeks?
DOWN TITRATE
Case: if a patient is on a biologic DMARD (etanercept, abatacept, rituximab, anakinra, myclopenolate) for RA and they present with a fever, what do you NEED to do?
stop the medication immediately!! figure out cause of infection and if it is long term or short term. If long term get them on a nonbiologic DMARD, but need a FULL WORKUP to determine the cause
Interesting: If someone needs to be be either downgraded to a nonbiologic DMARD or be put on one and they have KIDNEY DISEASE, what is the only nonbiologic DMARD they can take??? what must you monitor with this drug?
Hydroxychloroquinone
IOP, eye issues
Interesting: what must you monitor with hydroxychloroquinolone?
eye issues, IOP, vision all that jazz
Interesting: what can the biologic DMARD etanercept cause?
reactivation of hepatitus, TB, lymphoma, infection, varicella
Case: what is the only nasal spray you can use with a patient who has rhinnoreah?
cromolyn sodium
Case: what are some interesting foods that can greatly influence gout? (2)
Steak increases purine levels that get converted to uric acid then beer prevents it form being excreted from the body, increasing levels and promoting an acute gout
Interesting: how does gout present?
acute onset of right first MTP joint pain, nonsymmetric
Case: what is the DOC for a first occurance of gout without prior Hx? what should you not do with only 1 acute attack?
Schedule NSAIDS
with only one acute attack don’t start treatment/prophylaxis
what are two risk factors for gout?
weight and alcohol
Case: what is the DOC for gout in someone who can’t take NSAIDs because of risk for ulcers, GI bleed, CKD…or they don’t get symptom relief from taking them?
Colchicine
Interesting: what 3 medications can predispose a person for gout because they increase uric acid levels?
- ASA/aspirin
- thiazide/HCTZ
- diueretics-niacin
Interesting: what is the most common side effect with colchicine?
80% diaareah
Interesting: if a person has kidney stones what medication should they not take because it increases their risk for more kidney stones? why does it do this?
probenicid
blocks reabsortion and the PCL so more is excreted increasing the risk for kidney stones
Case: what is the DOC for a patient who takes allopurinol (prophylaxis) and they get an acute flare up of gout?
colchicine
Case: what drug should you give someone who has a histroy of 2 episodes of gout flare up a year and has modified their lifestyle to stop drinking and loose weight? (assuming you want to prevent this from happening again)
allopurinol
Interesting: what is an interesting characteristic of uric acid levels in individuals?
normal: 2.4-7.4
some people live outside of this range with increased levels but they don’t get gout….don’t treat anyone unless they are symptomatic, not just because of the high levels
what are some case presentations of osteoarthritis?
long term >3 years, typically without inflammation
Case: what is the DOC for a patient with osteoarthritis without inflammation?
acetaminophen
Case: what is the DOC for a patient with osteoarthritis WITH inflammation?
NSAID…ibuprophen
Case: what is the DOC for a patient with osteoarthritis WITH inflammation and a GI bleed?
selective COX2 inhibitor…..Celecobix
has less risk than ibuprophen
Case: what can you offer a patient who has osteoarthritis but can’t take oral NSAIDS or acetaminophen?
topical or transdermal NSAID, give pain relief without systemic effects or risk of bleeding
what is interesting about oral analgesics and NSAIDS?
they are equally effective
what is the daily max dosing of ibuprofen?
2400 mg
Case: what is the drug of choice for a patient with back pain from working in the garden or light activity? what do you need to tell the patient about this medication?
ibuprophen since likely inflammation
PAIN RELIEF within HOURS, but INFLAMMATION within 1-2 WEEKS!!!! (don’t see all the effects till much later than expected)
Case: what are the therapeutic goals when treating gout?
get the uric acid levels to 6 and the number of tophi to 5
Interesting: what is an interesting reaction you can get from mixing allopurinol for gout prophylaxis and ampicillin/amoxicillin?
YOU CAN GET A RASH!! BAM
Case: what is the DOC for pseudogout? what is the new DOC if the person can’t take that because of HTZ, CHF?
First DOC: NSAIDs (since inflammation)
Second DOC if patient can’t take them because they have HTZ or CKD: colchicine
Case: How does pseudogout present?
calcium deposits of calcium pyrophosphate crystals
what is important to make sure you aren’t missing when you see a hot, red, swollen joint?
SEPTIC JOINT
Case: what is the DOC for a woman with acute onset of back pain and spasms after lifting her 4 month old baby? what is the major caution with this??? alternative?
SPASMS: cyclobenzaprine CAN NOT USE IF NURSING, need to talk to the patient…if nursing
THEN
Just acetaminophen since can’t use NSAIDS in nursing!!
Interesting: what is the ONLY pain medication you can give a woman that is NURSING?
acetaminophen
Interesting: what is the best choice to use for a muscle relaxant in a patient who is PREGNANT?
cyclobenzaprine
Explain the best target locations for:
- cylcobenzapine
- baclofen
- dantrolene
- cylcobenzapine: back spasms
- baclofen: spine spasms
- dantrolene: periphreal spasms
Interesting: what should you caution of when using muscle relaxants?
sedation
Case: what is the DOC for a 45 year old woman with multiple sclerosis with back spasms in the limbs only?
baclofen…
since multiple sclerosis is a CNS disorder, want to treat where it starts rather than where it presents. so use this drug instead of other muscle relaxants
Caution: what should you NOT have with acetaminophen?
AVOID ALCOHOL!!
Caution: what should you caution when using baclofen?? (4)
- difficulty with ambulation
- sedation/slurred speech
- increase effects of alcohol
- increase opioids effects
how does polarteritis nodosa present?
foot drop
abdominal pain
subcutaneous nodules
livideo reticularis “fishnet rash”
Case: what is the drug of choice for polyarteritis nodosa? what else might you need to do?
prednisone high dose with cyclophosphamide–get rheum involed!
may need to be monitored on low dose predisone chronically
How does fibromyalgia present?
trigger points, fatigue, insomnia, muscle pain
Case: what is the DOC for a 30 year old with fibromyalgia? what drug class is this?
amitriptyline
tricyclic anti-depressent
what should you not prescribe to patients with fibromyalgia?
NSAIDS or narcotics! its CNS routed problem, not pain, risks addiction and negative side effects
how does giant cell arteritis present?
headache, scalp tenderness, temporal headache, blurred vision, jaw tenderness
Case: what is the DOC for a patient with giant cell arteritis?
prednisone high dose and then taper
what is the gold standard of treatment for giant cell artertitis?
temporal artery biopsy
who must you refer someone with giant cell arteritis to ASAP to prevent total blindness?
ENT
how does SLE present?
butterfly rash with PHOTOPHOBIA, malar rash, more common in african americans
Cases: what is the DOC for SLE?
hydroxychloroquinolone
Interesting: what do you NEED to do for a patient who is taking hydroxycholoroquinolone?
increased eye exams every 6-12 months
decrease alcohol use
what drugs can cause SLE? 5 drugs
procainimide hydralazine ischiazid quinidine chlorpromazine
how does sjrogrens present
eye irritation, dry mouth for longer than 3 months, difficulty eating, dysphagia
Case: what is the DOC for sjrogrens? what are alternative OTC things you can try?
pilocarpine
lemon drops, warm compress, saline eye drops, restasis, lacriminal duct plugs
what is the DOC for Raynauds?
NSAIDS
what should you counsel a patient with raynauds to stop doing to help eliminate the symptoms?
- wear gloves
- stops vasoconstrictors (smoking/decongestants)
- decrease stress and anxiety
what is the DOC for schleroderma?
calcium channel blocker or NSAIDS
