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PPT Phase II > Rheumatology and MSK PPT > Flashcards

Rheumatology and MSK PPT Flashcards

1
Q

What radiological changes do you see in OA?

A

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

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2
Q

What are teh non-pharmacological approaches to OA management?

A

weight loss if obese/overweight, physiotherapy, appropriate footwear, heat/cool packs, psychological support, assistive devices, joint supports

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3
Q

What pharmacological management option would you try first in someone with OA?

A

paracetamol +/- topical NSAIDs.

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4
Q

name two adjunct treatments that can be used in OA

A

topical capsaicin cream.

intra-articular steroid injections

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5
Q

What is the MOA of NSAIDs?

A

COX1 and COX 2 inhibitors

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6
Q

Name 4 side effects of NSAIDs

A

GI disturbance, renal insufficiency, salt/water retention, hyponatraemia/hyperkalaemia, CVS effects, hypersensitivity reactions, headaches/dizziness, skin reactiosn

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7
Q

why does the side effect profile of NSAIDs vary?

A

different drugs have different degrees of selectivity for COX-1 or COX-2.

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8
Q

when prescribing and NSAID, what steps can you take to reduce the risk of GI side effects?

A

lowest dose for the shortest time.
take with food.
prescirbe PPI alongside (being aware that PPIs carry their own risk).
consider a selective COX-2 inhibitor instead.

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9
Q

what group of people do you have to be cautious with if prescribing a COX-2 inhibitor?

A

those with ischaemic heart disease or risk factors for MI as it can increase risk of MI

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10
Q

why are NSAIDs contra-indicated in heart failure?

A

because they increase salt and water retention

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11
Q

why are NSAIDs avoided during 3rd trimester of pregnancy?

A

anti-prostaglandin effects prevent ductus arteriosus from closing

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12
Q

when would you consider referring a pt with OA for joint surgery?

A
  1. once person has been offered all/most non-surgical options
  2. if joint sx have a substantial impact on their QoL and are refractory to non-surgical treatment.
  3. if there are major limitations and pain.
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13
Q

is uric acid level a good indicator to rule out gout?

A

No - it is unreliable in the acute phase. normal uric acid level does nto rule out gout

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14
Q

what is needed to diagnose gout and rule out septic arthritis?

A

joint aspiration

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15
Q

how are gout crystals described under polarised light?

A

negatively birefringent, needle shaped

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16
Q

what are gout crystals made of?

A

monosodium urate

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17
Q

uric acid is the product of catabolism of what?

A

purines

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18
Q

what do pseudogout crystals look like under polarised light?

A

positively birefringent, rhomboid/rectangular shaped crystals

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19
Q

what are pseudogout crystals made of?

A

calcium pyrophosphate (CPP)

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20
Q

Name two medications that can increase risk of gout

A

diuretics, chemotherapy agents.

allopurinol when first started can precipitate gout becasue it can casue transient incraese in uric acid levels

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21
Q

why should allopurinol not be used in acute gout?

A

because it can precipitate gout as it can cause an initial transient increase in uric acid levels

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22
Q

what non-pharmacological advice can you give someone with gout?

A

rest, elevate limb, avoid trauma, ice-pack, basic analgesia with paracetamol.

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23
Q

what is first line drug option for gout?

A

NSAID or colchicine

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24
Q

what is the MOA of colchicine?

A

multiple anti-inflammatory actions. inhibits recruitment and action of neutrophil leucocytes in the joint, specific to a gouty joint. overall, prevents activation, migration and action of neutrophils within joint space.

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25
Q

what side effect do you need to stop colchicine immediately for if you get and why?

A

diarrhoea because it is a sign of it being toxic and destroying the gut lining.

26
Q

name two contra-indications for colchicine

A 
blood disorders
and pregnancy (teratogenic)
27
Q

name 4 drugs colchicine interacts with

A

increases toxicity of: macrolides, anti-virals/fungals, CCB, grapefruit juice.
increases risk of myopathy when given with lipid lowering therapy.

28
Q

what is the length of the colchicine course?

A

continue to take for 1-2 days after acute attack has resolved. however, it is restrictedto 3-6 days due to risk of toxicity

29
Q

what lifestyle advice can you give to someone to prevent gout attakcs?

A

weight loss, reduction in alcohol and red meat/seafood consumption, keep hydrated, regular exercise, low fat dairy products, smoking cessation

30
Q

how soon after a gout attack would you repeat blood tests to confirm hyperuricaemia?

A

4-6wks

31
Q

what is the first line urate lowering therapy available?

A

allopurinol

32
Q

should you start urate lowering therapy, such as allopurinol, during a gout attack?

A

no wait until acute attack has resolved as allopurinol can transiently increase uric acid levels initially.

33
Q

what is the MOA of allopurinol?

A

xanthine oxidase inhibitor

34
Q

how should you monitor allopurinol treatment?

A

check serum uric acid level and renal function every 4wks until within target range, then annually thereafter

35
Q

what is the target range of uric acid?

A

<300 micromol/l

36
Q

a pt who has been on allopurinol for 2yrs for prevention of gout comes and asks if it can nwo be stopped? what do you do?

A

explain that treated is usually life long to prevent recurrent attacks, tophi development and hyperuricaemia-induced renal disease (urate nephropathy, renal stones). However, can consider lowering dose to maintain serum uric acid between 300-360. can be more inclined to stop it if modifiable risk factors have been addressed adn a normal serum uric acid lvele has been achieved for many years

37
Q

what ix would you arrange in someone you supected had inflammatory arthritis?

A

RF, Anti-CCP, XR of affected joints.
consider FBC, U&Es, LFTs, for baeline.
could do ESR, CRP and PV whcih are usually raised but they may be normal.

38
Q

how long do DMARDs take to work on average?

A

3 months

39
Q

what is the MOA of methotrexate?

A

dihydrofolate reductase inhibitor. inhibits the enzyme which converts folic acid to tetrahydrofolate (fh4) which prevents cellular replication. also inhibits inflammatory mediators such as IL6, IL8 and TNF-alpha.

40
Q

which DMARDs are usually first-line in RA?

A

methotrexate, leflunomide, sulfasalazine, hydroxychloroquine

41
Q

what could you consider starting at the same time as a DMARD while waiting for it to work?

A

steroids

42
Q

what is MOA of sulfasalaziine?

A

its metabolites, 5-aminosalicylic acid (5-ASA) have antiinflammatory and immunosuppressive effects

43
Q

which DMARD can turn urine oragne?

A

sulfasalazine

44
Q

what allergy makes prescribing sulfasalazine contra-indicated?

A

aspirin allergy because it’s a salicylate

45
Q

name 4 side effects of sulfasalazine

A

GI disturbances, orange secretions, pancreatitis, blood disorders, hepato-renal toxicity, skin reactions, reversibel oligospermia

46
Q

when are biological therapies indicated in RA?

A

once steroids, two trials of 6 months of DMARD monotherapy or combo therapy (at least one including methotrexate) have failed.

47
Q

name 2 TNF-alpha inhibitors used in RA

A

infliximab, adalimumab, entanercept, golimumab

48
Q

how is infliximab given and how often?

A

IV injection. initially 2-4wkly then every 2 months

49
Q

name 4 side effects of infliximab

A

hypersensitivity reactions, HF/arrhythmias, skin disorders, lung problems, GI disorders, reports of blood disroders adn infectison

50
Q

name 5 things you should consdier before starting a pt on infliximab

A
  1. pts should be up to date with immunisations before initiating treatment.
  2. assess for active and latent TB and treat accordingly
  3. contraception cover is needed for 6 months after last dose.
  4. monitor for rreactivation of Hep B
  5. periodic skin examination for non-melanoma skin cancer
51
Q

how often are doses of methotrexate given?

A

once a week

52
Q

name 4 contraindications for methotrexate

A

active infection, ascites, pleural effusion, severe reanl impairment, teratogenic

53
Q

name 2 drugs that interact badly whit methotrexate

A

trimetoprim/co-tirmoxazole (severe BM depression) and NSAIDs (toxicity)

54
Q

how many months should men be off methotrexate before conceiving?

A

3-6 months

55
Q

what 5 important considerations are required when starting a pt on methotrexate?

A

avoid live vaccines (MMR, yellow fever, typhoid). co-prescribe folic acid to help prevent mucositis and myelosuppression. use appropriate contraception during and for at least 6 months after treatment in men and women
pre-screening tests

56
Q

what pre-screening tests are needed before starting methotrexate?

A

baseline FBC, U&Es, LFTs, pregnancy test if appropriate

57
Q

how often do you need to monitor person on methotrexate when they first start and what tests do you do?

A

do FBC, renal function and LFTs every 2wks until on stable dose for 6 wks

58
Q

once a pt is on stable dose of methotrexate, how often should you do monitoring bloods?

A

monthly FBC, renal funciton and LFTs for 3 months

59
Q

once pt has been on a stable dose of methotrexate for 3 months, how often shoudl you do monitoring bloods?

A

every 12wks at least. FBC, renal function and LFTs.

60
Q

a pt has their methotrexate dose incresed, how often do they need monitoring?

A

monitor every 2wks until dose is stable for 6wks. then can do monthly for 3 months then every 12wks

PPT Phase II (37 decks)

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