Random MSK - drugs Flashcards by Caitlin McMullen

What’s a dangerous side effect of paracetamol?

It is dangerous in overdose

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What are the side effects of NSAIDs?

Peptic ulceration
Renal impairment
Increased cardiovascular risk
Exacerbation of asthma

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Are biologic therapies more effective than DMARDs? Explain why.

Yes - a greater effect on the immune system. Because of their higher cost, in the UK tend to be used after failure of 2 DMARDs

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Side effects of Anti-TNF therapy

Increased risk of infection
Increased risk of skin cancer
Exacerbation of heart failure
Re-activation of latent tuberculosis

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Which of the following is NOT useful in treating an acute flare of gout?

Allopurinol
Naproxen
Prednisolone
Colchicine
Intramuscular steroid

Allopurinol

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What is the maximum daily dose of paracetamol for a >60kg patient?

1g up to 4x daily

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What does Paracetamol act on?

Cyclooxygenase 1 and 2

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Which drug is best suited to treat patients with Chronic Myeloid Leukaemia?

Imatinib

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What is the precursor to prostaglandins?

Arachidonic acid

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How is the alkalinisation of urine beneficial during salicylate poisoning?

Decreases salicylate reabsorption in the renal tubular cells

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Aspirin is derived from salicylic acid and acetic anhydride.

How do NSAIDs (Non-steroidal anti-inflammatory drugs) exert their anti-inflammatory effect?

Inhibition of cyclooxygenase

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A 60-year-old patient with rheumatoid arthritis is started on methotrexate.

What test is most important to perform before starting the drug?

LFT

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Omalizumab is a humanised monoclonal antibody directed towards another antibody involved in the pathophysiology of asthma.

Which antibody is it directed toward?

IgE

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What medication should be co-prescribed with methotrexate?

Folic acid

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What is a side effect of oral glucocorticoids?

Osteoporosis

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Chimeric antibodies were one of the earliest developments in immunotherapy.

Which drug is an example of a chimeric antibody?

Rituximab

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What is the most important thing to monitor in a patient taking hydroxychloroquine?

Vision

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Rituximab is an antibody that is used to treat B cell lymphoma. It binds to CD20 receptors that are found on all mature B cells (both malignant and normal B cells)

Describes why rituximab is an effective treatment, despite showing no selectivity for the malignant cells.

Immature B cells do not express the CD20 antigen. This means that the B cell population can regenerate from these immature cells following treatment with rituximab

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What medication can be used to manage rheumatoid arthritis during pregnancy?

Sulfasalazine

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NSAIDs exert their antipyretic effects by decreasing the production of which prostanoid in the hypothalamus?

Prostaglandin E2

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A middle-aged man presents to the Emergency Department with haematemesis and abdominal pain. He is subsequently diagnosed with a peptic ulcer. After resuscitation, he mentions that he has been taking ibuprofen for years. His doctor explains that this may have been the cause of the bleed. Why is this?

Reduced postganglion synthesis

An 84-year-old man presents with a 3-week history of heartburn and indigestion. He reports this started after a few days of starting a new medication. He has a background history of recurrent falls, right hip replacement, osteoarthritis, hypertension and diabetes mellitus.

What medication may be responsible for his complaint and why?

Alendronic acid
= Bisphosphonates can cause a variety of oesophageal problems

A 66-year-old postmenopausal woman comes to the office to discuss her bone densitometry results. She has a history of hypertension. She does not use tobacco, alcohol, or illicit drugs. Her body mass index (BMI) is 22.1 kg/m². Physical examination is unremarkable. Serum calcium, phosphorus concentrations and serum alkaline phosphatase activity are within the reference ranges. Bone densitometry reveals low bone density consistent with osteoporosis. The patient is prescribed a drug that inhibits osteoclast-mediated bone resorption. Repeat bone densitometry 1 year later reveals no further loss of bone mineral density.

Which medication was most likely prescribed to her?

Oral Bisphosphonates

= either alendronate, risedronate, or etidronate

You are a junior doctor working in orthopaedic surgery and have been asked to see a 44-year-old woman who is booked in for surgery tomorrow for repair of an open radial fracture sustained after falling from her bike. She has a past medical history of severe psoriasis, gastro-oesophageal reflux disease, polycystic ovary syndrome and depression. You order some routine blood before surgery, and are surprised by the following results:

Bilirubin 17 µmol/L (3 - 17)
ALP 89 u/L (30 - 100)
ALT 354 u/L (3 - 40)
γGT 61 u/L (8 - 60)
Albumin 34 g/L (35 - 50)

Which of her medications is most likely to be responsible for this derangement?

Methotrexate

A 45-year-old woman presents with substernal, crushing chest pain. Her ECG is unremarkable. She has a past medical history of rheumatoid arthritis controlled with methotrexate, hypertension and type II diabetes. Her body mass index is 34 kg/m² You decide to start her on aspirin. What is she at the greatest risk of? and why?

Bone marrow toxicity = Studies have shown that aspirin interferes with the clearance of methotrexate - this leads to an increased plasma level of methotrexate significantly increasing the risks of bone marrow toxicity.

A 23-year-old patient was recently admitted to hospital, presenting with diarrhoea, weight loss and abdominal pain. Blood tests showed a raised C-reactive protein (CRP) and anaemia. A stool test for faecal calprotectin was significantly raised. A colonoscopy was undertaken which demonstrated deep ulceration and skip lesions. He was given a diagnosis of Crohn's disease with no complications and promptly started on glucocorticoids to induce remission. Thereafter, the gastroenterologist starts the patient on a drug to maintain remission of his symptoms, called azathioprine. Describe the correct mechanism of this drug

It's metabolite inhibits purine synthesis

A 65-year-old retired firefighter presents to the general practice surgery with recurrent burning central chest pain. He finds the pain is worse after eating a takeaway and drinking alcohol and he feels that he is belching more than usual. Past medical history is significant for high cholesterol, type two diabetes and osteoarthritis. His medications are atorvastatin, metformin, gliclazide, naproxen and omeprazole which he often forgets to take. Which of his medications is the most likely cause of his symptoms? and why?

naproxen = Peptic ulcers are a side effect of NSAIDs and naproxen is an NSAID

A 52-year-old obese female with twice-yearly flares of crohn's disease has presented to the gastroenterology department with a flare. She was previously being managed well with steroids. After doing the thiopurine methyltransferase (TPMT) test she is started on a medication. A complete blood count done after a month of starting treatment shows : Hb 112 g/L Male: (135-180) Female: (115 - 160) Platelets 68 * 109/L (150 - 400) WBC 25 * 109/L (4.0 - 11.0) What is the drug most likely to be used to treat this patient's condition, and into which active compound is it most likely metabolised?

Azathioprine mercaptopurine - causes purine synthesis

A 27-year-old woman is referred to a rheumatology clinic as she has developed pain and stiffness in the small joints of her hands. She is diagnosed with rheumatoid arthritis and is started on methotrexate. Given her diagnosis and management, the risk of which side effect is reduced by giving a folate supplement?

myelosuppression

A 77-year-old woman is reviewed on the orthogeriatric ward round 5 days following a hemiarthroplasty for a fractured neck of the femur. The consultant decides to start her on a RANK ligand inhibitor for secondary prevention of osteoporosis. Which medication will you commence?

Denosumab

A 46-year-old female with poorly controlled rheumatoid arthritis and a history of significant large bowel resection. She has just had sulfasalazine, a prodrug, added to her medications, however, the consultant is worried that she will be unable to convert the prodrug into its active form with her shortened colon. Which therapeutically active compound is her medication converted to in the colon?

5-ASA (5-aminosalicylates)

You are sitting in with a GP as they do their morning consultations. A 65-year-old man has come to the clinic after routine blood tests showed elevated liver function tests over the last month, although he remains asymptomatic. This patient has little in the way of past medical history - osteoarthritis affects his knees (one of which underwent total replacement 3 months ago) and arthritis which affects the small joints of his hands and feet, well-controlled with medication. He also has hypertension, stable with medications. What drug can cause hepatic damage and therefore should be excluded in this case?

Immunosupressor drugs (eg) Methotrexate

What is the drug pilocarpine and what is it used for?

Pilocarpine is a cholinergic agent (muscarinic receptor agonist) used to: (1) Treat glaucoma by reducing eye pressure. (2) Relieve dry mouth (xerostomia) by stimulating saliva production. (3) It mimics acetylcholine to activate the parasympathetic nervous system

A 69-year-old woman with severe osteoarthritis attends her GP 1 month after being discharged from the hospital for an upper GI bleed. Her pain was well controlled with naproxen for several years prior to her GI bleed but this was stopped during her hospital admission. She complains that her pain is so severe and her quality of life so poor that she wishes to restart her naproxen despite the risks of another GI bleed. What drug is most appropriate for her situation and why?

Celecoxib = Celecoxib is a selective COX-2 inhibitor. Therefore she would have a lower risk of GI ulceration than regular NSAIDs because they inhibit COX-1 to a far lesser extent. COX-1 is protective for gastric mucosa

A 59-year-old man presents to the emergency department with acute abdominal pain. On examination, there is board-like rigidity over his abdomen and Chest X-ray reveals free air under the diaphragm. He has long long-standing history of gout and has been taking pain medication during the attacks.] Which medication has likely precipitated the underlying cause of this presentation?

An NSAID

A 51-year-old female with severe rheumatoid visits the rheumatology clinic. Her disease is severe despite various combinations of DMARDs and a 6-month trial of biologics and claims that her quality of life is very low. Her rheumatologist commences her on long-term prednisolone as a last resort. Why should she not receive the MMR (Measles, Mumps, Rubella) vaccine?

Is a live vaccine and therefore should not be given in severely immunosuppressed patients such as those on high dose steroid therapy = MMR Influenza BCG Oral polio Oral rota Typhoid Yellow fever

Under what circumstances can a patient abruptly stop steroids?

Oral courses of corticosteroids (less than 3 weeks) can be stopped abruptly. If the course was more than 40mg prednisolone or equivalent, the course needs slow withdrawal

A 25-year-old female with SLE is taking prednisolone 5mg daily for maintenance therapy. She presents to the Emergency Department with vomiting and diarrhoea more than 20 times in 2 days due to food poisoning. She is unable to keep her tablets down. What is the appropriate next step of action? and why?

IV hydrocortisone = For patients taking long term steroid therapy, abrupt cessation of steroid will cause adrenal insufficiency. In this case where patient is suffering from diarrhea, vomiting and struggle to keep her tablets down, IV injections of hydrocortisone can be given to prevent adrenal insufficiency

A 45-year-old female is seen by her rheumatologist with a new diagnosis of rheumatoid arthritis. He decides to start her on Methotrexate. What drug and dose should be considered prescribed with methotrexate?

Folic acid 5 mg once weekly on a different day to the Methotrexate.

A 28-year-old woman with rheumatoid arthritis presents to her GP with a 3-day history of dysuria and urinary frequency. She currently takes methotrexate, folic acid, ibuprofen, and paracetamol. She has no allergies. Which antibiotic has the greatest potential to have a dangerous interaction with her methotrexate?

Trimethoprim

How often should methotrexate be taken?

once weekly to avoid toxicity

A 43-year-old woman who has rheumatoid arthritis is reviewed in clinic. She has responded poorly to methotrexate and consideration is being given to starting sulfasalazine. An existing allergy to what drug may be a contradiction to the prescription?

Asprin

Patient on methotrexate. How long should you wait to try for a baby?

6 months

A 35-year-old woman with Crohn's disease is on azathioprine to maintain remission. She presents to her GP with a 3-day history of fever, lethargy, and coryzal symptoms. Due to her medication history the GP is concerned and ordered some investigations. What investigation is the most important in this situation?

FBC

Azathioprine and what drug has a severe interaction causing bone marrow suppression

allopurinol

A 45-year-old woman attends the rheumatology clinic with a 3-month history of progressive swelling and pain in her metacarpophalangeal joints bilaterally. The joints feel stiff, and in the morning, it takes her around an hour for them to 'loosen up'. She has a set of bloods taken to test for rheumatoid factor, which comes back positive What is the most common form of rheumatoid factor antibody?

IgM against IgG

systemic lupus erythematosus (SLE) is associated with what drug?

Hydroxychloroquine

Alendronic acid

27-year-old woman is referred to a rheumatology clinic as she has developed pain and stiffness in the small joints of her hands. She is diagnosed with rheumatoid arthritis and is started on methotrexate. Given her diagnosis and management, the risk of which side effect is reduced by giving a folate supplement?

Myelosuppression

Deranged LFT - Bilirubin, ALP, ALT, γGT, Albumin Suggests what drug

Methotrexate

Reduced prostaglandin synthesis

MOA of ibuprofen

Ibuprofen will act as an antagonist at COX-2, which decreases the conversion of arachidonic acid to prostaglandin E2