Muskuloskeletal

Question 1

What are the symptoms of rheumatoid arthiritis?

Answer 1

Swollen, hot, stiff and motionless joints

Question 2

What are the risks of DMARDs

Answer 2

Blood dyscrasia
- high risk of infections

Question 3

Which DMARD causes orange tears and urine?

Answer 3

Sulfasalazine

Question 4

What are the risks of cyclophosphamide?

Answer 4

Haemorrhagic cystitis and permanent male sterility

Question 5

What are the risks of leflunomide?

Answer 5

Hepatotoxicity
Effective contraception after treatment - men for 3 months and women for 2 years

Question 6

What are the risks of chloroquine?

Answer 6

Retinopathy - screen for ocular toxicity

Question 7

What is the treatment pathway for arthiritis?

Answer 7

1st line: conventional DMARD
- oral methotrexate, lefluonmide, sulfasalazine

2nd line: combination of 2 conventional DMARDs

3rd line: cytokine modulators

DMARDs can take 2-3 months to reduce inflammation therefore, corticosteroids (or sometimes NSAIDs) can be used for this short-term and during flare-ups

Question 8

How do you treat severe active RA?

Answer 8

methotrexate + rituximab

Question 9

How is methotrexate taken for autoimmune conditions?

Answer 9

Once weekly on a specific day

Question 10

What are the MHRA warnings for methotrexate?

Answer 10

overdose of methotrexate for non-cancer treatments
- only one strength tablet is prescribed
- decide on a day of the week to take

Question 11

What is the missed dose advise for methotrexate?

Answer 11

If the missed dose is >3 days = continue with next schedule dose

If day or two later - take as soon as they remember

If vomit within a few hours of taking - do NOT take a second dose

Question 12

What if the purpose of prescribing folic acid with methotreaxte?

Answer 12

Help reduce anti-folate side effects of methotrexate e.g. mucositis and may also prevent hepatotoxicity

Question 13

When should folic acid be taken?

Answer 13

DO NOT take on the same day as methotrexate because it will reduce the therapeutic effects of methotrexate and antagonise it

Possible regimens:
- 5mg once weekly, different day to methotrexate
- 1 or 5mg daily except on the day methotrexate is taken

Question 14

What are the side effects of methotrexate?

Answer 14

• Immunosuppression - can occur if take daily instead of weekly
• Blood disorders e.g. neutropenia and low red blood cells which can lead to anaemia and thrombocytopenia
  (low white blood cell weakens immune system = increases risk of infections)
• Nephrotoxicity (monitor renal function)
• Hepatotoxicity: monitor LFTs, report liver disorders
  C/I ascites
• Pulmonary toxicity: report respiratory effects
  C/I significant pleural effusion
• GI toxicity: stop if stomatitis or diarrhoea
• Phototoxicity: sunburns and blisters

Question 15

What are the contraindications of methotrexate?

Answer 15

Active infections
Immunodeficiency syndromes e.g. HIV

Question 16

What counselling do you need to provide to a patient taking methotreaxte?

Answer 16

Fever
Sore throat
Mouth ulcers
Bruising
Bleeding

Question 17

What can be used for acute methotrexate toxicity?

Answer 17

Folinic acid

Also prevents immunosuppression especially when used to treat cancer with high doses

Question 18

How long after methotrexate must contraception continue?

Answer 18

6 months - men and women
- may be present in breastmilk, do not breastfeed

Question 19

What drugs interact with methotrexate?

Answer 19

Blood disorder:
- Trimethoprim - both are anti-folate drugs and can cause bone marrow suppression = blood disorders
- Clozapine
- Phenytoin (anti-folate)
- Cytotoxic
- Immunosuppressants

Reduced renal clearance = methotrexate toxicity:
- NSAIDs (both nephrotoxic): avoid taking at the same time
- Penicillins
- PPI

Nephrotoxicity
- aminoglycosides
- Cephalosporin
- Ciclosporin
- Tacrolimus
- NSAIDs

Hepatotoxicity
- co-amoxiclav
- fluclox
- tetracyclines
- carbamazepine
- valporate
- fluconazole
- isoniazid
- sulfasalazine

Question 20

What are the symptoms of oesteoarthiritis?

Answer 20

Stiff motionless joints
- usually weight-bearing joints

Question 21

What is the treatment for oesteoarthiritis?

Answer 21

1st line: topical NSAID
- Oral NSAID
- Paracetamol or weak opioid

Question 22

What are the symptoms of gout?

Answer 22

Sudden severe intense joint pain, swelling and purple-red shiny skin

Over time with frequent and severe attacks - tophi can form

Question 23

Which drugs worsen or exacerbate gout?

Answer 23

Loop and thiazide diuretics

Cytotoxic drugs

Ciclosporin and tacrolimus

Question 24

How is an acute gout attack treated?

Answer 24

NSAIDs - not aspirin

Colchicine - max dose 500mcg BD-QDS
- no repeat course in 3 days

Oral corticosteroid

Question 25

How is the prevention of gout treated?

Answer 25

1st line allopurinol Or Febuxostat Never start during attack Can trigger an acute gout attack when started If gout attack occurs during prevention - continue as normal and treat gout attack separately

Question 26

What are the MHRA warnings for febuxostat

Answer 26

Hypersensitivity reactions - anaphylaxis or steven-johnsons syndrome Cardiovascular disease

Question 27

How is allopurinol taken?

Answer 27

With or just after food

Question 28

What are the side effects of allopurinol?

Answer 28

Rash - stop if mild and reintroduce slowly - stop if reoccurs

Question 29

What are the interactions of allopurinol?

Answer 29

Azathioprine and mercaptopurine toxicity = reduce doses of these by 25-50% Hypersensitivity with ACEi Skin rash - penicillins

Question 30

What is the uses of quinine?

Answer 30

Antimalarial drug Nocturnal leg cramps - only use for this if regular sleep disturbances - failed non-pharmacological treatments - frequent or very painful

Question 31

What are the side effects of quinine?

Answer 31

Toxic in overdose - convulsions, arrhythmias Blindness, tinnitus - C/I: tinnitus and optic neuritis QT prolongation - conduction abnormalities - risk factors = hypokalaemia

Question 32

What is baclofen used for?

Answer 32

Chronic severe spasticity e.g. in multiple sclerosis - in palliative care

Question 33

What is the side effects of baclofen?

Answer 33

Drowsiness Muscular hypotonia Avoid abrupt withdrawal - withdrawal symptoms

Question 34

What are the side effects of NSAIDs?

Answer 34

Asthma and dyspnoea NSAID hypersensitivity - asthma attack, urticaria, rhinitis Photosensitivity - topical Nephrotoxicity - can cause AKI Odema Hypertension Bleeding Hyperkalaemia

Question 35

Which NSAIDs cannot be given in any history of GI ulcer or bleeding even if it wasnt cause by an NSAID?

Answer 35

Ketoprofen Ketorolac Piroxicam These have the highest risk of GI toxicity

Question 36

What drugs interact with NSAIDs?

Answer 36

Nephtotoxicity - aminoglycosides - cephlosporin - glycopeptide - ciclosporin and tacrolimus - methotrexate Renal clearance = toxicity - lithium - methotrexate Bleeding - alcohol - anticoagulants - warfarin - corticosteroids - SSRI - venlafaxine Hyperkalaemia - ACEi/ ARB - ciclosporin and tacrolimus - heparin - potassium-sparing diuretics - trimethoprim Seizures - quinolones