Musculoskeletal system Flashcards
(17 cards)
What is rheumatoid arthritis?
Chronic systemic auto-inflammatory disease affecting joint synovial membrane, resulting in:
* Pain/stiffness which worsens with rest and heat
* Nodules, swelling and tenderness in the joints
* Fatigue
* Fever
* Weight loss
Treatment of RA
Before specialist appointment: bridge with corticosteroids for rapid suppression and NSAIDs for pain relief. To be stopped when controlled by DMARD.
- DMARDs: Methotrexate, Leflunamide, or Sulfasalazine (Hydroxychloroquine in mild RA)
- MAbs: Adalimumab, Tocilizumab, Infliximab, Etanercept, Barictinib
Lifestyle: physio, exercise, relaxation and stress management.
Methotrexate adverse effects
- Blood disorders - report sore throat, bruising, mouth ulcers
- Hepatotoxicity - report abdominal pain, dark urine, jaundice, itchy skin, N&V
- Nephrotoxicity
- Pulmonary toxicity - report SOB and coughing
- GIT toxicity - stomatitis and diarrhoea
- Photosensitivity - avoid high UV and direct sun exposure
- Antifolate so harmful to foetal growth - rule out pregnancy before & both men and women must use effective contraception during treatment and for 6 months after
Methotrexate toxicity antidote
Folinic acid aka calcium folinate
Methotrexate interactions
- Hepatotoxic drugs e.g., antifungals, rifampicin
- Nephrotoxic drugs - do not give NSAIDs OTC
- Anti-folates e.g., trimethoprim, phenytoin
- Omeprazole/esomeprazole - reduced clearance and increased risk of toxicity
What is hyperuricaemia and gout?
Raised plasma uric acid conzcentrations (hyperuricaemia) causing deposition of urate crystals in joints and other tissues (gout).
Causes of hyperuricaemia/gout
- High salt diet
- Meds e.g., bendroflumethiazide, bempedoic acid, chemo.
Treatment of acute gout
First: line:
Colchicine 500mcg 2-4x/day for 3 days (do not repeat course within 3 days) i.e., 3 days on, 3 off etc
OR
High dose NSAID (not aspirin) + PPI (risk of fluid retention - avoid in pts with HF, on diuretics etc)
Second line:
Short course of oral corticosteroid
OR
IM corticosteroid
OR
Canakinumab
How is chronic gout managed and when is drug-treatment offered?
A xanthine oxidase inhibitor to prevent formation of uric acid, either:
* Allopurinol
* Febuxostat (caution in CVD)
Offered if 2+ gout attacks in a year.
How should an acute gout attack be managed in a patient taking chronic gout treatment?
Continue the chronic treatment and take the acute treatment as well until managed.
Key points for allopurinol
- When initiating treatment, flare prophylaxis with colchicine/NSAID recommended.
- Can cause hypersensitivity. If rash occurs, discontinue and reintroduce slowly. Discontinue if reccurs.
- Interacts with thiopurines - reduce dose.
How are nocturnal leg cramps managed?
Quinine sulfate to reduce frequency.
Advice for qunine sulfate for nocturnal leg cramps.
- MAY reduce frequency of cramps
- Potential toxicity - only use if cramps regularly disrupt sleep, are very painful, or other pain releif hasn’t worked
- Trial for 4 weeks and only continue if beneficial
- Stop treatment every 3 months and assess need for continuation
Risk of NSAIDs causing GI side effects
High: Piroxicam, Ketoprofen, Ketorolac
Medium: Indometacin, Diclofenac, Naproxen
Low: Ibuprofen
Lowest: COX-2 inhibitors
Risk of NSAIDs causing cardiovascular side effects
High: COX-2 inhibitors, Diclofenac, Ibuprofen 2.4g
Low: Ibuprofen 1.2g, Naproxen
When should NSAIDs be avoided?
- Asthma - bronchospasm
- Hypersensitivity reactions - cross-sensitivity with aspirin
- Aspirin and alcohol - increase GI bleed risk. Use PPI.
- Renal impairment & AKI - risk of fluid retention and further impairment
- Pregnancy >20 weeks
NSAIDs interactions
- MTX - reduced clearance
- Lithium - reduced clearance
- Ciprofloxacin - increased seizure risk
- Blood thinners, SSRIs, bisphosphonates, steroids, carbocisteine - increased risk of GI bleed.
- Hyperkalaemic drugs (THANKS B)
- Nephrotoxics - risk of AKI
