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Pre-reg revision > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

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1
Q

Which of these drugs is NOT a DMARD?

  • Methotrexate
  • Gold
  • Leflunamide
  • Colchicine
  • Hydroxychloroquine
A

Colchicine

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2
Q

How long do DMARDs take to work?

A

Varies, but can take 2-6 months for full effect

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3
Q

When should a DMARD be changed for a different one?

A

If not objective benefit in 6-12 months

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4
Q

How does methotrexate work?

A

Anti-folate - inhibtis dihydrofolate reductase

Prevents cellular replication

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5
Q

Dose of MTX for these conditions?

  • RA
  • Crohns
  • Psoriasis
A

RA - max 20mg weekly
Crohns - 10-25mg weekly
Psoriasis - max 30mg weekly

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6
Q

What should a methotrexate prescription include?

A
  • Dose
  • Frequency
  • Only one strength should be prescribed and dispensed
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7
Q

Contra-indications for MTX?

A
  • Active infection - as immunosuppression
  • Ascites - as risk of accumulation
  • Immunodeficiency syndrome
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8
Q

What can increase the risks of toxicity from methotrexate?

A
  • Increasing age
  • Renal impairment
  • Use of other anti-folates eg, trimethoprim
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9
Q

How does the BNF recommend folic acid is used with methotrexate?

A

5mg weekly on a different day to methotrexate

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10
Q

Why is folic acid given with methotrexate?

A

To reduce GI and mucosal side effects and may prevent hepatotoxicity

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11
Q

What advice should be given to patients about contraception whilst on methotrexate?

A

Effective contraception should be used during treatment and for at least 3 months after treatment in both men and women
MTX is teratogenic and fertility may be reduced

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12
Q

Can MTX be used in hepatic and renal impairment?

A
  • Avoid in hepatic impairment unless it is for malignancy

- High doses may be neprotoxic - moniotr renal func

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13
Q

What patient counselling should be given with methotrexate?

A
  • Use effective contraception during + 3 months following treatment
  • Avoid OTC NSAIDs
  • Report any signs of blood disorders, liver toxicity or pulmonary toxicity
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14
Q

What monitoring is required for methotrexate?

A

FBC + renal and liver function tests

Every 2 weeks until treatment stabilised

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15
Q

Which blood disorders may be caused by methotrexate?

A

Decreased WBCS - signs of infection
Decreased RBCs - signs of anaemia
Decreased platelets - bruising and bleeding

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16
Q

What are some interactions with methotrexate?

A

NSAIDs - reduced renal excretion due to vasoconstriction of arteries can lead to toxicity
Drugs with risk of blood disorders - phenytoin, trimethoprim, clozapine etc
Hepatotoxic drugs - isotretinoin, rifampicin, ketoconazole

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17
Q

What monitoring is required for a patient on hydroxychloroquine?

A

Monitor vision/visual changes - risk of ocular toxicity with long-term treatment

  • Before treatment determine baseline vision and renal/liver func and adjust dose if necessary
  • Monitor vison annually and ask pt to report any changes eg, blurred vision
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18
Q

What patient couselling should be given with Leflunomide?

A
  • Risk of blood disorders, report any signs and need FBC monitoring
  • Risk of liver toxicity - do not drink alcohol and LFTs need to be taken every 2 weeks for the first 6/12, potentially life-threatening
  • Contraception is essential during treatment, continue for 2 years after treatment in women and 3 months in men
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19
Q

Why might leflunomide need a ‘wash-out’ with activated charcoal or colestyramine?

A

Has a very long half life

May need a washout if serious side effects occur, before another DMARD is initiated or before conception

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20
Q

How long do men and women who want to concieve have to wait following treatment with leflunomide?

A

Men - 3 months of effective contraception
Women - 2 years following treatment

Sr levels must be <20mcg/L before conception

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21
Q

Can you give penicillamine to a patient with a penicillin allergy?

A

No, patients with penicillin allergy may rarely react to penicillamine

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22
Q

What is sodium aurothiomalate?

A

Gold - DMARD

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23
Q

What are the major side effects of Gold?

A
  • Blood disorders
  • Pulmonary fibrosis - annual chest xray
  • Rashes with pruritis
  • Nephritis + proteinuria, need regular urine tests
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24
Q

Which of these would NOT cause hyperuricaemia/gout?

  • Tacrolimus
  • Cancer
  • Liver impairment
  • Furosemide
  • Chemotherpay
A

Liver impairment

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25
How should an acute gout attack be treated?
1. High doses of NSAIDs diclofenac, naproxen, etoricoxib, indometacin, ketoprofen 2. If NSAIDs C/I then colchicine 3. Oral/parenteral corticosteroids
26
Which NSAIDs are NOT indicated in the treatment of an acute gout attack?
Ibuprofen + aspirin
27
How should colchicine be prescribed in an acute gout attack?
500mcg 2-4 times/day | No more than 6mg in a course, do not repeat the course within 3 days
28
How would you treat an acute gout attack in a patient with severe heart failure?
Colchicine - no fluid retention | All NSAIDs are contra-indicated in severe heart failure
29
How should long term prevention for gout be initiated?
- Never in an acute attack, 1-2 weeks after attack has settled - Initiation of treatment may precipitate an acute attack, use prophylactic NSAID/colchicine until hyperuricaemia has been corrected for one month
30
How would you treat an acute gout attack in a patient taking allopurinol?
- Continue allopurinol in same dosage | - Treat attack separately with high-dose NSAIDs/colchicine
31
What drug is first line for gout prophylaxis?
Allopurinol
32
When used for prophylaxis of hyperuricaemia associated with chemotherpay, when should allopurinol be started?
BEFORE chemotherapy | 100-200mg daily
33
How should a patient starting allopurinol be counselled?
- Take with food - Ensure adequate fluid intake (2-3 L per day) - Prophylactic NSAID will need to be taken until hyperuricaemia has been corrected for a month (usually for around 3 months)
34
Can allopurinol be used in renal impairment?
Yes | Max 100mg per day
35
What drugs does allopurinol interact with?
Mercaptopurine/azathioprine | Reduce dose by 1/2 - 1/4 as risk of toxicity
36
Which drug is 2nd line for gout prophylaxis?
Febuxostat
37
How long is a prophylactic NSAID usually needed for when starting febuxostat?
6 months
38
Which MHRA warning is associated with febuxostat?
Risk of serious hypersensitivity reactions - inc SJ syndrome + anaphylaxis - Usually happens in first month of treatment - Advise pts to recognise signs
39
How dose sulfinapyrazone work?
Uricosuric drug - increases excretion of uric acid in the urine
40
Why is it important for patients taking sulfinapyrazone to have adequate urine output?
Urine is made alkaline and urea crystals can form | Need good renal function and urine output
41
Can sulfinapyrazone be given to a patient with a hypersensitivity to aspirin?
No - avoid if hypersensitivity to aspirin/salicylates
42
When is sulfinapyrazone use cautioned?
- Cardiac disease | - Salt and water retention
43
In which cirumstances can quinine be used for nocturnal leg cramps?
- Sleep is disturbed or cramps are very painful/frequent - Treatable causes of cramps have been excluded - Non-pharmacological options do not work eg, passive stretching
44
Why is the use of quinine for leg cramps restricted?
Can be toxic in overdose | Risk of QT prolongation
45
What side effects are associated with baclofen?
- Drowsiness | - Muscular hypotension
46
Which of these is NOT a reaction caused by abrupt withdrawal of baclofen? - Hyperactive state - Hypoglycaemia - Psychiatric reaction - Hyperthermia - Convulsions
Hypoglycaemia
47
How long do NSAIDs take to work to full effect?
Pain relief after first dose Full analgesia after one week Anti-inflammatory effect after 3 weeks
48
What is the mechanism of action of NSAIDs?
Reduce production of prostaglandins by inhibiting the enzyme cyclo-oxygenase
49
Which NSAIDs selectively inhibit COX-2?
Celecoxib, parecoxib, etorocoxib
50
What is high dose ibuprofen?
2.4g daily
51
'Ibuprofen has a weaker anti-inflammatory effect than the other NSAIDs' True or false?
True | Unsuitable if inflammation is prominent eg in gout
52
Which NSAID is the drug of choice for inflammation?
Naproxen | Good efficacy and low incidence of side effects
53
When can naproxen be sold OTC?
Primary dysmenorrhoea Women aged 15-50 Max 750mg/day for 3 days (feminax ultra)
54
What side effects are associated with indometacin?
Headache, dizziness + GI toxicity (medium) | May affect driving
55
Which side effects with mefenamic acid would mean that the treatment should be discontinued?
- Diarrhoea - Haemolytic anaemia - Rash
56
Why is piroxicam reserved for specialist use only?
High risk of GI toxicity and serious skin reactions - Max 20mg OD - Review treatment every 2/52 - Should consider giving with gastro protection - Not 1st line, specialist for RA, ASp, OA
57
What side effect is associated with phenylbutazone?
Haemotological reactions
58
What are the GI + cardiovascular risks with selective COX-2 inhibitors such as celecoxib?
LOW risk for GI side effects | HIGH risk for cardiovascular events
59
Which selective COX-2 inhibitor can be used in gout?
Etorocoxib
60
What side effect can be seen with use of topical NSAIDs?
Photosensitivity eg, ketoprofen
61
Can you drink alcohol with NSAIDs?
Should be fine within daily recommened limits | Alcohol increases risk of GI haemorrhage and AKI has been linked to excess alcohol use with NSAIDs
62
How do NSAIDs affect renal function?
Nephrotoxic They reduce GFR and are renally cleared Risk in AKI
63
Due to sodium and fluid retention, NSAIDs are cautioned in which conditions?
HTN, renal imp, liver imp, congestive heart failure
64
'All NSAIDs are contra-indicated in severe heart failure' | True or false?
TRUE
65
Which NSAIDs are commonly used for dental pain?
Ibuprofen + diclofenac
66
Why should NSAIDs be avoided in pregnancy?
- Can delay labour or prolong labour - Can cause pulmonary hypertension in the newborn - Can cause premature closure of foetal ducts
67
Which group of patients are high risk for GI toxicity with NSAIDs?
Elderly | Should be given with gastroprotection
68
Which NSAIDs are lowest risk for GI toxicity?
Ibuprofen and selective COX-2 inhibitors
69
Which NSAIDs have the highest risk for GI toxicity?
Ketoprofen, Ketorolac, Piroxicam
70
Which NSAIDs are intermediate risk for GI toxicity?
Naproxen, diclofenac, indometacin
71
Can more than one type of NSAID be used at once?
No NSAID + low dose aspirin = increased GI risk Only use if absolutely necessary + monitor closely
72
Which NSAIDs are NOT associated with an increased risk of thrombotic events?
All NSAIDs are associated with the risk independent of CV risk factors or treatment duration
73
Which NSAIDs have the HIGHEST cardiovascular risk?
Diclofenac (150mg) High dose ibuprofen (2.4g) Selective COX-2 inhibitors Acelofenac
74
Which NSAIDs have low cardiovascular risk?
Standard dose ibuprofen (< 1.2g) | Naproxen
75
Which is NOT a contra-indication for NSAIDs? - Ischaemic heart disease - Uncontrolled hypertension - Asthma - Oedema - Left ventricular dysfunction
Asthma - but use with caution as can worsen asthma and cause bronchospasm
76
Some interactions with NSAIDS?
Risk of AKI - ACEi, ciclosporin, tacrolimus, diuretics Bleeding risk - warfarin, DOACs, heparin, SSRIs, steroids Reduced renal excretion (toxicity) - lithium, methotrexate Hyperkalaemia - K+ sparing diuretics Convulsions - quinolones
77
What age can children be given ibuprofen OTC?
Over 3 months
78
Paediatric doses for ibuprofen?
``` 3-5 months - 50mg TDS 6 - 11 months - 50mg 3-4 times/day 1 - 3 years - 100mg TDS 4 -6 years - 150mg TDS 7 - 9 years - 200mg TDS 10 - 11 years - 300mg TDS 12 - 17 years - 300-400mg 3-4 times per day ```

Pre-reg revision (14 decks)

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