Musculoskeletal System

Question 1

What are acute attacks of gout usually treated with?

Answer 1

NSAIDs (not aspirin) or colchicine

Question 2

What should be co-prescribed with NSAIDs

Answer 2

PPI

Question 3

Canakinumab (IL-1 inhibitor) can be prescribed for gout when frequent attacks occur how often? (Or patients who have inadequate control to standard treatment)

Answer 3

At least 3 attacks in the previous 12 months

Question 4

Serum urate level for diagnosis of gout

Answer 4

360 micromol/L (6mg/dL)

Question 5

What class of drug is allopurinol and how does it work?

Answer 5

Xanthine oxidase inhibitor

it reduces the formation of uric acid from purines via the enzyme xanthine oxidase.

NB never start during an acute attack, start 1-2 weeks after

Question 6

What do you do if a rash occurs on starting allopurinol?

Answer 6

If mild, reintroduce slowly, stop if the rash occurs again.

Question 7

How much do you dose reduce azathioprine/mercaptopurine with allopurinol?

Answer 7

¼ to ½ reduction

Question 8

What is offered as an alternative to allopurinol?

Answer 8

Febuxostat

Question 9

When do you start the urate lowering therapy?

Answer 9

After the inflammation in an acute attack has settled.

NB: the initiation or up titration of a urate lowering therapy may precipitate an acute attack and therefore colchicine should be considered as prophylaxis as an option.

NSAIDs low dose with PPI is an alternative

Question 10

What is the maximum amount of colchicine used per course?

Answer 10

6mg per course

Question 11

When can you repeat colchicine courses, how much time must you leave in between two courses?

Answer 11

3 days

Question 12

Colchicine has an increased risk of myopathy with which drugs?

Answer 12

Statins, fibrates, digoxin and ciclosporin

Question 13

What is the MHRA alert for febuxostat?

Answer 13

Serious hypersensitivity reactions with febuxostat including SJS usually in the first month. Stop if occurs.

Question 14

Give an example of a skeletal muscle relaxant?

Answer 14

Baclofen, tizanidine, diazepam

Question 15

In Rheumatoid arthritis, is pain and stiffness worse after exercise or rest?

Answer 15

RA pain is worsened by periods of inactivity/rest

Question 16

List some drug causes of RA/gout

Answer 16

Hyperuricaemia

(diuretics, ciclosporin, tacrolimus, cytotoxics, cancer)

Question 17

How do you treat RA (pharmacological)?

Answer 17

DMARD- either oral methotrexate, leflunomide or sulfasalazine

Question 18

What is the onset of action for a typical DMARD?

Answer 18

2-3 months

NB: up titrate to the max tolerated dose

Question 19

What medicine would you bridge with when starting a DMARD?

Answer 19

A corticosteroid to provide rapid symptomatic control

Question 20

Give a weak DMARD

Answer 20

Hydroxychloroquine

Question 21

What would you give if an DMARD was not enough to treat?

Answer 21

Add another DMARD i.e. methotrexate, leflunomide, sulfasalazine and hydroxychloroquine

Question 22

What colour does sulfasalazine turn bodily secretions?

Answer 22

Orange/brown

Question 23

What contraception do you need to give when patients are on leflunomide?

Answer 23

For 2 years after treatment for women

3 months after for men

Question 24

MOA of methotrexate

Answer 24

Inhibits the conversion of dihydrofolate to tetrahydrofolate- which is needed to make purines and pyrimidines and therefore DNA – prevents cellular replication

Question 25

When is the dose of methotrexate?

Answer 25

Once weekly

Question 26

What are the side effects of methotrexate?

Answer 26

Blood dyscrasias: low WBC, anaemia, thrombocytopenia. Hepatotoxicity. Nephrotoxicity. Pulmonary toxicity: report SOB and cough and fever. GI toxicity- report stomatitis, first sign of GI toxicity.

Question 27

When is contraception given after MTX?

Answer 27

During and three months after for both men and women

Question 28

What is first line for osteoarthritis?

Answer 28

Simple analgesia- paracetamol and topical NSAIDs, regular rather than PRN if pain uncontrolled. When topical isn’t controlling- use oral NSAIDs, then opoiods

Question 29

What is myasthenia gravis?

Answer 29

Muscle weakness- a neuromuscular disorder. Commonly affects muscles of eyes, eyelids, facial expressions, chewing, swallowing and speaking. Autoimmune

Question 30

What do you use to treat Myasthenia Gravis?

Answer 30

Anticholinesterases: neostigmine, pyridostigmine. Anticholinesterases are first line and as an adjunct to immunosuppressive therapy. Immunosuppressants: corticosteroids, azathioprine, methotrexate. Corticosteroids are used when anticholinesterases cannot control symptoms completely. A second line immunosuppressant is used frequently to reduce dose of corticosteroid.

Question 31

What are the side effects of the anticholinesterases?

Answer 31

Muscarinic- increased sweating, salivary and gastric secretions, GI, uterine motility and bradycardia

Question 32

What medicine is used in nocturnal leg cramps?

Answer 32

Quinine

Question 33

Why quinine cannot routinely used?

Answer 33

Because of toxicity, it is toxic in overdoses and accidental fatalities have occurred; it should only be prescribed when it has caused regular disruption to sleep and cramps are really painful.

Question 34

List some serious SEs with quinine

Answer 34

QT prolongation, convulsions, arrhythmia

Question 35

What is the MHRA alert with quinine?

Answer 35

Reminder of dose dependent QT prolonging effects, caution in patients with risk factors for QT prolongation or in those with atrioventricular block

Question 36

What does the COX1 pathway target?

Answer 36

Stomach, intestines, kidneys and platelets.

Question 37

What does COX 2 target?

Answer 37

Inflammatory sites, macrophages

Question 38

Which is the most cox 2 specific NSAID?

Answer 38

Etoricoxib (celecoxib slightly less cox 2 specific)

Question 39

Which NSAIDs are best to use in CV disease?

Answer 39

Low dose ibuprofen or naproxen (NO to diclofenax or COX 2 specific)

Question 40

Which NSAID has the highest risk of GI events?

Answer 40

Ketoprofen, piroxicam

Question 41

What would you recommend for analgesia in lower back pain?

Answer 41

Oral NSAIDs, paracetamol alone is ineffective. A weak opioid can be used if the NSAID is ineffective or not tolerated.