Gout, OA, OP, RA, Acne, Lupus, Atopic Dermatitis

Question 1

how long does it take gout to spontaneously resolve, what is something non pharm you can do

Answer 1

3-10 days, apply ice topically, lose weight to prevent future attack, remain hydrated

Question 2

common factors for acute attack (causes)

Answer 2

acute illness, surgery, trauma, alcohol, high purine diet, drugs (alcohol, cyclosporine, diuretics, levodopa, niacin, salicylates, tacrolimus, teriparatide)

Question 3

first line treatments for gout, when should they be initiated

Answer 3

NSAIDs, (high dose then back off when sx controlled) colchicine, oral steroids- initiate within 24 hours of acute attack. Can use combo of any agents if severe, but avoid NSAID and steroid for increased GI tox

Question 4

how to dose colchicine for gout

Answer 4

1.2mg now, 0.6mg 1 hour later (total 1.8 first day), then 0.6-1.8mg per day

Question 5

most patients have a recurrent gout attack ___-_____ )time frame) after first one

Answer 5

6-24 months

Question 6

what foods should be avoided in gout

Answer 6

alcohol (esp beer), limit red meat (beef/lamb/pork/seafood), fish, limit salt, limit sweetened beverages (fructose and corn syrup), ENCOURAGE low fat or non fat dairy an veggies

Question 7

what are the urate lowering therapies, which is preferred

Answer 7

neither preferred, zanthine oxidase inhibitors =allopurinal and febuxostat

Question 8

how to initiate allopurinol

Answer 8

start low dose and titrate up, start 1-2 weeks after acute flare but don’t d/c it if flare occurs while on therapy,

Question 9

max dose naproxen

Answer 9

1500mg in gout or very short term, usually 1000mg, and 440 OTC

Question 10

celecoxib max dose

Answer 10

400-800mg per day

Question 11

common side effects with: colchicine, allopurinol

Answer 11

colc; N/V/D, allo; rash, D. TAKE BOTH WITH MEALS

Question 12

dosing of allopurinol and how it helps manage SE, do you need to ever adjust dose?

Answer 12

start low and titrate to avoid rash, if dose over 300mg (ie usual dose) divide doses for better tolerability, max dose 800mg daily. Adjust in renal impairment. Use colchicine or NSAID for 3-6 months while this starts to work

Question 13

febuxostat SE

Answer 13

N, arthralgia, rash

Question 14

2 drugs not indicated for gout that can be used to lower uric acid

Answer 14

losartan and fenofibrate

Question 15

what interacts with colchicine

Answer 15

3a4 and pgp inhibitors. *fatalities reported with clarith b/c inhibits both. In normal renal or hepatic fx, just decrease colchicine dose. If impaired, CI

Question 16

first line for OA, then order of therapies

Answer 16

non pharm and topical analgesisc, then acetaminophen, then add on or change to low dose NSAID, then full dose NSAID or cox2 inh, tramadol if absolutely necessary (watch for SS!) but avoid all other opioids if at all possible

Question 17

non harm for OA

Answer 17

exercise, weight loss, orthotics/aids

Question 18

compare topical diclofenac to oral NSAIDs in OA

Answer 18

shown to be just as effective with less SE for hand and knee pain. Should be used for those 75 and older for sure

Question 19

when is duloxetine a good choice in OA

Answer 19

if concurrent depression or neuropathic pain

Question 20

advice on glucosamine

Answer 20

allow 4-8 weeks to see benefit if any, evidence is mixed, safe, may be effective short term

Question 21

what kind of OA is hyaluronic acid effective in

Answer 21

knee only possibly

Question 22

when are the advantages of cox 2 inhibitors (less GI tox) negated?

Answer 22

when used with low dose ASA

Question 23

when is pharm therapy indicated for OP?

Answer 23

considered if moderate 10 yr fracture risk (10-20%), use if high risk

Question 24

what things automatically make people high risk for OP or bump them up a category

Answer 24

hip or vertebral fracture after menopause or age 50, corticosteroid therapy pred 7.5 or more mg per day for three months or greater OR fragility fracture move up one category for each

Question 25

non pharm for OP

Answer 25

regular exercise (esp impact), reduce risk of falls, smoking cessation, encourage calcium and vit D intake, avoid excessive alcohol (more than 2 drinks) or caffeine (more than 4 cups)

Question 26

first line for OP

Answer 26

alendronate and risedronate, then etidronate (not as good- only prevents vertebral, not hip or non vertebral #)

Question 27

counselling for bisphosphonates

Answer 27

all have poor F and absorption so must be on an empty stomach with water only as food and meds will prevent absorption. Do half hour before food, big glass of water to prevent GI and esophageal irritation, stay upright for 30 minutes after. Osteonecrosis of jaw rare-tell dentist taking these. Atypical subtrocanteric fracture possible (rare)- femur (presents as thigh pain usually)

Question 28

when are drug holidays for bisphosponates considered

Answer 28

2-5 years? if on for 3-5 years already and only low risk usually, sometimes moderate as effect persists and med sits in bone for years after

Question 29

what is raloxifene, SE

Answer 29

SERM- leg cramps, hot flashes and flushing, only for OP_ post menopausal, only decreases risk of vertebral fracture

Question 30

what is teriparatide, SE, who is it for

Answer 30

OP- parathyroid hormone analoge that acts as an anabolic agent and builds bone vs preventing resorption. Se- N, dizzy, syncope. For those who are losing BMD even on antiresorptive therapy, for those with prior frag frac and very low BMD less than 3, patients who continue to fracture on therapy.

Question 31

what is denosumab

Answer 31

OP- aka prolia- rank ligand inhibitor

Question 32

non pharm RA

Answer 32

appropriate amounts of exercise (lots of muscle strength building), heat/cold

Question 33

what should a patient be started on at diagnosis of RA? what is RA?

Answer 33

RA- autoimmune symmetric joint swelling. Start on DMARd (methotrexate is gold standard, hydroxychloroquine, sulfasalazine, leflunomide)at dx with or without corticosteroid

Question 34

how long does it take most non biologic DMARDs to work

Answer 34

3-6 months

Question 35

what is an adequate trial of methotrexate for RA? What are major SE? how to reduce?

Answer 35

20-25mg PO for at least 3 months. GI and liver dysfx- folic acid minimum 5mg weekly.

Question 36

when are hydroxychloroquine or sulfasalazine used in RA?

Answer 36

early mild disease or combined with methotrexate for mod to severe disease

Question 37

name the biologic response modifiers (biologic DMARDs) for RA, how soon do they work?

Answer 37

tnfalpha antagonists- adalimumab, certolizumab, etanercept, golimumab, infliximab. Work in 8-12 weeks

Question 38

what role do NSAIDs play in RA

Answer 38

pain relief, but no effect on underlying disease process

Question 39

what role do corticosteroids play in RA, and which is preferred and why

Answer 39

rapidly decrease inflam and may modify disease, but aren’t recommended for routine use due to SE. Pred is drug of choice at 10mg or less per day due to moderate glucocorticoid potency, intermediate DOA, and low mineralcorticoid potency

Question 40

treating RA during pregnancy

Answer 40

steroids safest at lowest effective dose, MTX CI and should be stopped f3months prior to conception, no NSAIDs in 3rd tri, sulfasal and hydroxychol are less well studied but likely safe, leflunomide CI. Breastfeeding is same

Question 41

first line therapy for lupus

Answer 41

hydroxychloroquine with or without NSAIDs and or steroids prn for sx control.

Question 42

what is hydroxychloroquine good for in lupus? What is required with it?

Answer 42

fatigue, rashes, photosensitivity and arthritis. Requires regular opthalmic assessment. SE= GI, cramps, HA and nightmares

Question 43

what is most often combined with steroids in lupus and why

Answer 43

steroid sparing agents to reduce CS AE- methotrexate, azathioprine, cyclophosphamide, mycophenolate mofetil

Question 44

how can you “wash out” leflunomide

Answer 44

cholestyramine 8g TID for 11 days- enhances elimination is pregnancy considered

Question 45

how soon should isotretinoin be stopped before becoming pregnant

Answer 45

1 month

Question 46

topical retinoids in pregnancy

Answer 46

systemic are CI and teratogenic, as it is not known what happens with topical they are also CI

Question 47

should spironolactone be used in preg?

Answer 47

avoid- cat c on lexi- anti androgenic effects

Question 48

what is eczema

Answer 48

inflammatory disorder of skin that creates abnormal barrier and can’t maintain adequate hydration- patches of redness, scaling, excoriations, dry skin, itch

Question 49

first line therapy for eczema

Answer 49

emollients BID and after bathing if mild dry. If dermatitis (more severe- red, scale, excor), use steroid or barrier. If doesn’t work, use calcineurin inh

Question 50

non pharm for eczema

Answer 50

no perfumes, non irritating soap, emollients like petrolatum to hold moisture in at least BID, bath only 5-10 minutes in warm not hot water and pat dry, apply emollients within 3 minutes of drying. Decrease stress/sweat and over heating as all can aggravate and increase itch.

Question 51

1st line pharm for eczema and how to use/what to expect

Answer 51

steroids- OD sufficient, use low potency for skin fold and face, med for body and scalp and high for palms and soles. Use for a few days to several weeks at a time (some improvement within 2 for sure)

Question 52

which formulations should not be used in eczema and why

Answer 52

lotion and gel- alcohol base will sting and irritate open areas of eczema

Question 53

tacrolimus and picrolimus vs steroids

Answer 53

both for eczema, calcineurins need BID dosing for sure and work more slowly. Long term safety in terms of malignancy is questioned with calcineurins inh. For patients over 2, intermittent use as second line therapy.

Question 54

preventing flares of eczema

Answer 54

steroids 2-3x per week, emollients always

Question 55

best formulation choice in eczema

Answer 55

ointments- less irritating and penetrate best.

Question 56

antihistamines and eczema

Answer 56

not useful as histamine is not the mediator of itch in this case