Musculoskeletal Disorders Flashcards
What would be the BEST choice for treatment of acute gout in someone with no contraindications?
a) Colchicine 0.6mg once daily
b) Indomethacin 75mg stat then 50mg q6h x 2 days, then 50mg q8h x 1 day, then 25mg q8h x 1 day
c) Allopurinol 100mg daily
d) Celecoxib 100mg bid
B. NSAIDS are the first choice in treatment of acute gout. Dose of colchicine is 1.2mg initially, then 0.6mg 1 hour later (page 967, CTC, 7th edn). Allopurinol is used as a prophylactic agent to prevent further attacks. The regimen for celecoxib is 800mg stat, then 400mg on day 1, and then 400mg bid x 7days.
Which of the following statements regarding gout treatment is/are TRUE?
a) Indomethacin is more effective than other NSAIDs in the treatment of gout.
b) Colchicine should be as first line therapy in patients with acute gout and renal failure (CrCl < 10
mL/min)
c) Febuxostat can be used for patients with severe renal insufficiency
d) Allopurinol is not associated with gastrointestinal side effects.
e) None of the above
C. All NSAIDs are equally effective for treating gout – though indomethacin is traditionally used more. Colchicine is contraindicated in those with severe renal failure. Very small quantities of febuxostat are excreted renally (page 971, CTC, 7th edn). Allopurinol is associated with several GI adverse effects.
When considering the treatment of gout, all of the following are true EXCEPT:
a) Start with allopurinol 100mg daily and gradually titrate upwards
b) There is not a clear relationship between obesity and gout
c) Colchicine 0.6mg twice daily will reduce the possibility of an acute flare
d) The patient should be told to avoid alcohol intake
e) Indomethacin 25mg twice daily will reduce the possibility of an acute flare
B. The starting dose of allopurinol is 100mg daily, gradually increased and titrated to urate levels. Obese patients should lose weight to achieve an ideal BMI and incorporate healthy lifestyle changes (page 969, CTC, 7th edn). Alcohol, all types, should be avoided. Colchicine or, if it cannot be used, a low-dose NSAID reduces the risk of an acute flare when therapy with allopurinol is started.
Which of the following statements regarding the use of NSAIDs in the treatment of rheumatoid
arthritis is/are TRUE?
a) They are safe when used during early pregnancy (first or second trimester)
b) Patients with heart disease should be on concurrent low-dose ASA
c) Misoprostol should be added if the patient is at risk of peptic ulcer disease
d) NSAIDs are used initially in patients with rheumatoid arthritis to reduce joint pain and swelling.
e) All of the above
E. NSAIDS are considered safe during the first two trimesters of pregnancy but should not be used in the last month due to the risk of fetal and maternal bleeding, premature closure of the ductus arteriosis and interference with labour (pg 1052, CTC 7th edn). The efficacy of traditional NSAIDs and COX-2 inhibitors are similar. Appropriate gastroprotection (misoprostol or a PPI) should be used if a patient is at risk of peptic ulcer disease. Increased cardiovascular events may be linked to the inhibition of COX-2 by NSAIDs.
Which is the following is FALSE regarding osteoporosis?
a) Raloxifene is the agent of choice for the prevention and treatment of corticosteroid-induced osteoporosis
b) Safety of bisphosphonates in renal impairment is unknown
c) Patients taking teriparatide should be in a supine or sitting position during administration due to
risk of orthostatic hypotension
d) Zoledronic acid is given as a 5mg IV infusion once a year
A. Bisphosphonates are the agents of choice for the prevention and treatment of corticosteroid- induced osteoporosis (page 1030, CTC 7th edn). Safety of bisphosphonates in renal impairment (<35ml/min) is unknown (page 1031, CTC 7th edn).
Red Flags by condition and drug induced conditions: Gout
DRUG INDUCED Gout & Hyperuricemia
Pg 966 table 1
Drugs that cause Hyperuricemia:
● alcohol
● cyclosporine
● diuretics
● ethambutol
● interferon + ribavirin* (not fr CTC)
● levodopa
● nicotinic acid
● pyrazinamide
● salicylates, low dose
● tacrolimus
● teriparatide
● theophylline*
Conditions that cause gout: Alcohol excess, atherosclerosis, chronic kidney (glomerular, interstitial renal disease), diabetes, hyperlipidemia, HTN, Lead intoxication (niacin), Ischemic Ht dz, metabolic Syndrome, myeloproliferative disorders, some cancers, obesity, dietary factors, urolithiasis history rarely genetic or acquired causes of uric acid overproduction
Red Flags by condition and drug induced conditions: Osteoporosis
Fracture Risk
Aromatase inhibitors
Anticoagulants (unfractionated and low molecular weight heparins)
Antiretroviral therapy
Cyclosporine,
Depo-medroxyprogesterone acetate, OCP, hormonal therapy
Corticosteroids therapy, (at least 3 months cumulative therapy in the previous year at a prednisone equivalent dose > 7.5mg daily),
Loop diuretics
Proton pump inhibitors (PPIs)
SSRIs
Thiazolidinediones.
High dose vitamin A are associated with increased risk of hip fracture so patients should not take double doses of multivitamins to try to increase their vitamin D intake.
High dose L-T4 (Levothyroxine: eltroxin, synthroid) incrs fracture risk in elderly
Red Flags by condition and drug induced conditions: Osteoporosis
BISPHOSPHONATES ADVERSE EFFECTS
Osteonecrosis of the jaw (1-3% in ↑-dose, monthly IV), definite risk of esophageal ulcerations, but controversial evidence for esophageal cancer, atypical subtrochanteric (stress-like) fractures have been observed and may or may not be related to excessive suppression of bone turnover
Red Flags by condition and drug induced conditions: Pain
INT CODEINE
● Inhibitors of CYP2D6 may antagonize effects (Amiodarone, cimetidine, fluoxetine, moclobemide, paroxetine, quinidine)
● Additive CNS depressant
● Should not be used in breastfeeding mothers → CNS/respiratory depression in infant
Red Flags by condition and drug induced conditions: Pain
COX2
CI in Hx of PUD, CV risk factors, renal failure, heart failure or asthma
Red Flags by condition and drug induced conditions: Pain
IBUPROFEN (NSAID)
● Worsens HTN, HT failure
Red Flags by condition and drug induced conditions: Pain
NSAIDs
○ 1-2%risk of GI bleed, enteric coating does nothing
○ common cause of ST and bowel disorders (stomach upset, ulcers to perforation and fatal GI bleedi)
○ mixed with EtOH, likely the most common drugs to produce drug-induced high blood pressure
○ NSAIDs will, in some people, reverse some of the beneficial effects of drugs used in patients with heart failure and they can damage kidney function in susceptible individuals
○ Some NSAIDs can cause mental confusion, especially in the elderly
○ NSAIDs do not retard or prevent the progression of either rheumatoid or osteoarthritis
Risk Factors for upper GI AE w/NSAIDs
● Age ≥65
● Comorbid condition (CVD, alcoholic LV dz, RA)
● High dose NSAID
● Use of anticoagulants or oral glucocorticoids
● Hx of upper GI bleed
● Presence of H.Pylori infection
○ Use of multiple NSAIDs (inc. low-dose ASA)
Red Flags by condition and drug induced conditions: Pain
NSAID & COX2
CI in Hx of PUD, CV risk factors, renal failure, heart failure or asthma
Red Flags by condition and drug induced conditions: Pain
INT NSAIDs (Inc. ASA)
● May ↑ anticoagulant effects, caution w/warfarin
● May ↓ effects of antihypertensives (requiring add’l therapy to control BP)
● Lithium may interfere with sodium/water balance, clearance also decreased → must monitor serum levels if adding an NSAID
● Risk of GI bleed increases if patient is on SSRI
● Higher risk of GI mucosal damage if taking 1+ NSAIDs (inc. Bismuth subsalicylate)
