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Module 1: Mali Rheum/MSK > Pharm Rheum/MSK > Flashcards

Pharm Rheum/MSK Flashcards

1
Q

what do you use to treat acute musculoskeletal conditions

A
  1. RICE
  2. oral and topical analgesics
    - acetaminophen, tNSAIDS, COX2
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2
Q

what do you use to treat osteoarthritis?

A

acetaminophen, tNAIDS, COX 2

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3
Q

how does acetaminophen decrease pain?

A

decreases CNS and spinal cord prostaglandin production

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4
Q

what is a example of a topical NSAID used to treat acute muskuloskeletal conditions

A

diclofenac (gel or patch)

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5
Q

what is the name of a local anesthetic used to treat acute musculoskeletal pain? what forms does it come in?

A

lidocaine

aerosol, cream, gel, spray, solution, transdermal patch

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6
Q

what are 4 counter irritants used to treat acute musculoskeletal pain?

A
  1. methyl salicylate (Ben Gay, Icy Hot)
  2. Methol (icy hot)
  3. Methyl nicotinate
  4. capsaicin
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7
Q

what are the 5 thing used to treat acute muscloskeletal conditions?

A
  1. RICE
  2. acetaminophen
  3. tNSAIDs
  4. local anesthetics
  5. counter irritants
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8
Q

what are the 8 possible treatments for osteoarthritis?

A
  1. exercise
  2. weight loss
  3. acetominophen
  4. tNSAIDS
  5. glucosamine (chronic pain ~6 weeks)
  6. tramadol (ultram, ryzolt) aka codeine and opoids
  7. intra-articular steroids, hyaluronic acid
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9
Q

what are the proinflammatory mediators associated with RA? (4)

A

TNF-alpha
IL-1
IL-6
IL-17

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10
Q

what are the anti-inflammatory mediators associated with RA? (2)

A

IL-4

IL-10

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11
Q

what do the drugs of RA target?

A

the inflammatory intermediates

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12
Q

what are the significant comorbidities seen with RA (4)

A
  1. cardiovascular disease
  2. infections
  3. malignancy
  4. osteoporosis

these comorbidities are lethal, so need to control them with other drugs

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13
Q

what are the treatment timing goals of RA? what do you treat with? what are the two treatment approaches?

A

DMARDS within 3 months of diagnosis

  1. step up therapy
  2. step down therapy (preferred)
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14
Q

what do you need to be cautious of in the treatment of RA?

A

pregnancy

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15
Q

what 3 main things does RA stimulate?

A
  1. t-lymphocytes
  2. cytokine release
  3. B-lymphocytes
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16
Q

when T-lymphocytes are activated in RA, this causes what four things?

A
  1. macrophages to release cytokines
  2. activation of osteoclasts
  3. activation of matrix metaloproteases that degrades connective tissue
  4. B cells to make antibodies
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17
Q

what does the activation of B cells cause in RA?

A

antibodies and increase in RF and CRP

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18
Q

what are the four major groups of drugs that can be used to treat or relieve pain of RA?

A

MEDS THAT RELIEVE SYMPTOMS
1. tNSAIDS, COX2

MEDS THAT REDUCE PROGRESSION AND PAIN

  1. glucocorticoids: global anti-inflammatory/immune suppression
  2. non-biologic DMARDS
  3. biologic DMARDS
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19
Q

what is the pathophys of gout?

A

uric acid crystals in joint spaces leads to inflammation and pain, increased uric acid crystals

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20
Q

what medications can you use to treat gout? (4)

A
  1. NSAIDS: acute episodes and prophylaxsis
  2. colchicine
  3. corticosteroids: acute joint injection or systemic (IM or PO)
  4. antihyperuricemic prophylaxis ( 3 drugs)
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21
Q

what are the three antihyperuricemic prophylaxis drugs? (3) what do they do?

A
  1. allopurinal- reduces uric acid production
  2. febuxostat- reduces uric acid production
  3. probenicid- uricosuric aka increases excretion of uric acid by preventing tubular reabsorption
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22
Q

what is a caution of using probenicid in patients for gout?

A

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!!

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23
Q

what is a characteristic of the COX-1 enzyme? where is it found?

A

constitutive

gastric mucosa, kidney, platelets

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24
Q

what is a characteristic of the COX-2 enzyme? where is it found?

A

inducible (by injury)

most tissues, injury induced

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25
Q

Cox-1 stimulates what two hormones?

A

prostaglandins

thromboxanes

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26
Q

prostaglandins do what two things in COX1?

A

protect gastric mucosa and dilate afferent artery of the glomerus

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27
Q

thromboxanes do what two things?

A

vasoconstriction

platelet aggregation

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28
Q

Cox1 stimulates what two hormones? what are those hormones functions?

A
  1. prostaglandins
    - protect gastric mucosa
    - dilate afferent artery of the glomerus
  2. thromboxanes
    - vasoconstriction
    - platelet aggregation
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29
Q

COX-2 stimulates what two hormones?

A
  1. prostaglandins

2. prostacylcines

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30
Q

what do prostaglandins do when activated by COX-2 ?

A

pain, fever

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31
Q

what do prostcyclins do when activated by COX-2?

A

vasodilation and anti-platelet activity

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32
Q

Cox-2 enzyme activates which two hormones when induced? and what are their functions?

A
  1. prostaglandins
    - fever
    - pain
  2. prostacyclins
    - vasoconstriction
    - anti-platelet activity
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33
Q

tNSAIDS block which enzymes and hormones?

A

BOTH COX1 and COX2

blocks all prostaglandin, thromboxane, and prostacycline hormones

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34
Q

the COX-2 selective inhibitors block what enzyme and hormones? what are the benefits to this? what are the negatives?

A

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

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35
Q

what are 5 risk factors for adverse effects from NSAIDS

A
  1. Hx of peptic ulcer disease (PUD) or proton pump inhibitor (PPI)
  2. high dose NSAID
  3. use with anticoagulants, corticosteroids, multiple NSAIDS
  4. > 75 years old
  5. serious underlying disease like CKD, HF
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36
Q

what 3 drugs should you caution using when taking NSAIDS because it can set you up for increase risk for adverse effects?

A
  1. anticoagulants
  2. corticosteroids
  3. multiple NSAIDS
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37
Q

what can you expect to see pain relief from tNSAIDs?

A

pain relief within hours but full anti-inflammatory activity takes 2-3 weeks of continuous use

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38
Q

How does RA present?

A

-wrist, MCP, PIP joint involvement bilaterally

-

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39
Q

what is a DOC for RA? what else do you want to prescribe this with?

A

methotrexate plus NSAIDS

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40
Q

interesting: what do you also need to always prescribe when giving methotrexate for RA?

A

Leucovorin aka folic acid/B12

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41
Q

how is leucovorin (B12) dosed when it is given to a RA patient taking methotrexate?

A

5mg day after taking methotrexate, or 1 mg daily

42
Q

interesting: what function to NSAIDS often take but what don’t they solve?

A

Bridge therapy, but don’t cure the disease, only the pain so make sure to treat the cause!

43
Q

interesting: what is the standard of care for RA patients?

A

get on DMARD within 3 months

44
Q

interesting: what pregnancy category is methotrexate so what do you need to monitor?

A

X!!!!!!! NOOOOO

monitor pregancy

45
Q

interesting: what do you need to do before and after starting methotrexate?

A

need to ALWAYS get a xray before and after because it can cause pulmonary fibrosis so need to establish a baseline view

46
Q

Case: if patient is unresponsive to methotrexate what should you do before switching meds? what is the max dose?

A

uptitrate this dose, max is 25 mg

47
Q

What do you need to do for prednisone if the patient wants to stop the medication and it has been longer than two weeks?

A

DOWN TITRATE

48
Q

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?

A

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

49
Q

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?

A

Hydroxychloroquinone

IOP, eye issues

50
Q

Interesting: what must you monitor with hydroxychloroquinolone?

A

eye issues, IOP, vision all that jazz

51
Q

Interesting: what can the biologic DMARD etanercept cause?

A

reactivation of hepatitus, TB, lymphoma, infection, varicella

52
Q

Case: what is the only nasal spray you can use with a patient who has rhinnoreah?

A

cromolyn sodium

53
Q

Case: what are some interesting foods that can greatly influence gout? (2)

A

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

54
Q

Interesting: how does gout present?

A

acute onset of right first MTP joint pain, nonsymmetric

55
Q

Case: what is the DOC for a first occurance of gout without prior Hx? what should you not do with only 1 acute attack?

A

Schedule NSAIDS

with only one acute attack don’t start treatment/prophylaxis

56
Q

what are two risk factors for gout?

A

weight and alcohol

57
Q

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?

A

Colchicine

58
Q

Interesting: what 3 medications can predispose a person for gout because they increase uric acid levels?

A
  1. ASA/aspirin
  2. thiazide/HCTZ
  3. diueretics-niacin
59
Q

Interesting: what is the most common side effect with colchicine?

A

80% diaareah

60
Q

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?

A

probenicid

blocks reabsortion and the PCL so more is excreted increasing the risk for kidney stones

61
Q

Case: what is the DOC for a patient who takes allopurinol (prophylaxis) and they get an acute flare up of gout?

A

colchicine

62
Q

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)

A

allopurinol

63
Q

Interesting: what is an interesting characteristic of uric acid levels in individuals?

A

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

64
Q

what are some case presentations of osteoarthritis?

A

long term >3 years, typically without inflammation

65
Q

Case: what is the DOC for a patient with osteoarthritis without inflammation?

A

acetaminophen

66
Q

Case: what is the DOC for a patient with osteoarthritis WITH inflammation?

A

NSAID…ibuprophen

67
Q

Case: what is the DOC for a patient with osteoarthritis WITH inflammation and a GI bleed?

A

selective COX2 inhibitor…..Celecobix

has less risk than ibuprophen

68
Q

Case: what can you offer a patient who has osteoarthritis but can’t take oral NSAIDS or acetaminophen?

A

topical or transdermal NSAID, give pain relief without systemic effects or risk of bleeding

69
Q

what is interesting about oral analgesics and NSAIDS?

A

they are equally effective

70
Q

what is the daily max dosing of ibuprofen?

A

2400 mg

71
Q

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?

A

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)

72
Q

Case: what are the therapeutic goals when treating gout?

A

get the uric acid levels to 6 and the number of tophi to 5

73
Q

Interesting: what is an interesting reaction you can get from mixing allopurinol for gout prophylaxis and ampicillin/amoxicillin?

A

YOU CAN GET A RASH!! BAM

74
Q

Case: what is the DOC for pseudogout? what is the new DOC if the person can’t take that because of HTZ, CHF?

A

First DOC: NSAIDs (since inflammation)

Second DOC if patient can’t take them because they have HTZ or CKD: colchicine

75
Q

Case: How does pseudogout present?

A

calcium deposits of calcium pyrophosphate crystals

76
Q

what is important to make sure you aren’t missing when you see a hot, red, swollen joint?

A

SEPTIC JOINT

77
Q

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?

A

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!!

78
Q

Interesting: what is the ONLY pain medication you can give a woman that is NURSING?

A

acetaminophen

79
Q

Interesting: what is the best choice to use for a muscle relaxant in a patient who is PREGNANT?

A

cyclobenzaprine

80
Q

Explain the best target locations for:

  1. cylcobenzapine
  2. baclofen
  3. dantrolene
A
  1. cylcobenzapine: back spasms
  2. baclofen: spine spasms
  3. dantrolene: periphreal spasms
81
Q

Interesting: what should you caution of when using muscle relaxants?

A

sedation

82
Q

Case: what is the DOC for a 45 year old woman with multiple sclerosis with back spasms in the limbs only?

A

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

83
Q

Caution: what should you NOT have with acetaminophen?

A

AVOID ALCOHOL!!

84
Q

Caution: what should you caution when using baclofen?? (4)

A
  1. difficulty with ambulation
  2. sedation/slurred speech
  3. increase effects of alcohol
  4. increase opioids effects
85
Q

how does polarteritis nodosa present?

A

foot drop
abdominal pain
subcutaneous nodules
livideo reticularis “fishnet rash”

86
Q

Case: what is the drug of choice for polyarteritis nodosa? what else might you need to do?

A

prednisone high dose with cyclophosphamide–get rheum involed!

may need to be monitored on low dose predisone chronically

87
Q

How does fibromyalgia present?

A

trigger points, fatigue, insomnia, muscle pain

88
Q

Case: what is the DOC for a 30 year old with fibromyalgia? what drug class is this?

A

amitriptyline

tricyclic anti-depressent

89
Q

what should you not prescribe to patients with fibromyalgia?

A

NSAIDS or narcotics! its CNS routed problem, not pain, risks addiction and negative side effects

90
Q

how does giant cell arteritis present?

A

headache, scalp tenderness, temporal headache, blurred vision, jaw tenderness

91
Q

Case: what is the DOC for a patient with giant cell arteritis?

A

prednisone high dose and then taper

92
Q

what is the gold standard of treatment for giant cell artertitis?

A

temporal artery biopsy

93
Q

who must you refer someone with giant cell arteritis to ASAP to prevent total blindness?

A

ENT

94
Q

how does SLE present?

A

butterfly rash with PHOTOPHOBIA, malar rash, more common in african americans

95
Q

Cases: what is the DOC for SLE?

A

hydroxychloroquinolone

96
Q

Interesting: what do you NEED to do for a patient who is taking hydroxycholoroquinolone?

A

increased eye exams every 6-12 months

decrease alcohol use

97
Q

what drugs can cause SLE? 5 drugs

A 
procainimide
hydralazine
ischiazid
quinidine
chlorpromazine
98
Q

how does sjrogrens present

A

eye irritation, dry mouth for longer than 3 months, difficulty eating, dysphagia

99
Q

Case: what is the DOC for sjrogrens? what are alternative OTC things you can try?

A

pilocarpine

lemon drops, warm compress, saline eye drops, restasis, lacriminal duct plugs

100
Q

what is the DOC for Raynauds?

A

NSAIDS

101
Q

what should you counsel a patient with raynauds to stop doing to help eliminate the symptoms?

A
  • wear gloves
  • stops vasoconstrictors (smoking/decongestants)
  • decrease stress and anxiety
102
Q

what is the DOC for schleroderma?

A

calcium channel blocker or NSAIDS

Module 1: Mali Rheum/MSK (4 decks)

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