Session 6 Flashcards
(18 cards)
What is rheumatoid arthritis?
Autoimmune, multisystem disease. It initially localises to synovium, causing proliferation and subsequent dissolution of cartilage and bone
What are the clinical features of RA used for diagnosis?
At least 4 of the following
Morning stiffness for more than an hour most morning for 6 weeks
Arthritis of 3 or more joints (including a hand joint for extra point) for 6 weeks
Symmetrical arthritis
Rheumatoid nodules
Serum rheumatoid factor
X ray changes
What is the treatment strategy for RA?
Early diagnosis and early use of disease modifying antirheumatic drugs (DMARDs)
Avoidance of long term corticosteroids
What are the treatment goals in SLE and vaculitis?
Symptomatic relief (e.g. arthralgia, Raynaud’s), reduction in mortality and long term morbidity, prevention of organ damage
What is the mechanism of action for corticosteroids?
Prevent interleukin (IL)-1 and IL-6 production by macrophages. Inhibit all stages of T cell activation.
What is the first line treatment for RA?
Two DMARDs and one short term glucocorticoid
E.g. methotrexate, sulfasalazine and prednisolone
Why are TPMT levels checked before prescribing azathioprine?
TPMT metabolises the drug - if low TPMT levels are present there is a risk of myelosupression
What is the pathophysiology of asthma?
Smooth muscle dysfunction - increased contraction and cytokines
Airway remodeling - mucous gland hyperplasia, subepithelial fibrosis, epithelium desquamation, wall thickening
Inflammation - T cells, mast cells, eosinophils
Give an overview of the stepwise therapy of asthma in adults
1 - mild intermittent asthma, SABA (move up if 3 or more per week)
2 - regular preventor therapy, add low dose ICS
3 - add on therapy, add LABA, then increase ICS dose
4 - persistent poor control, high ICS dose, add 4th drug
5 - oral steroids or biological therapies (anti-IgE)
Step down recommended after control
What are indications of good asthma control?
Minimal symptoms during day and night, minimal need for reliever medication, no exacerbations, no limitation of physical activity, normal lung function (FEV1 and PEF)
What steps should be taken before initiating a new asthma drug therapy?
Check compliance with existing therapies, check inhaler technique, eliminate trigger factors
Outline the drugs used and mechanism of action for step 1 asthma therapy
Short acting beta2 agonist - salbutamol or terbutaline
Used for symptom relief through reversal of bronchoconstriction. If used regularly they reduce asthma control (mast cell degranulation in response to allergen increases).
When should a patient be stepped up from step 1 to step 2?
Using SABA 3 or more times a week
Symptoms 3 or more times a week
Waking 1 or more times a week
Consider if exacerbation requiring oral steroids in last 2 years
What are the benefits of inhaled corticosteroids in asthma?
Improve symptoms and lung function, reduce exacerbations and prevents death
What are alternative step 3/4 add on drugs?
Leukotriene receptor antagonists (LTRA) - montelukast
Theophylline - adenosine receptor antagonist
Tiotropium - long acting anticholinergic (LAMA)
What is acute severe asthma?
One of: unable to complete sentences, HR greater than 110, RR greater than 25, peak flow 33-50% best or predicted
What is the treatment of acute severe asthma?
High flow O2 to keep sats 94-98%
Nebulised salbutamol
Oral prednisolone for 10-14 days Add IV hydrocortisone if very ill
If fails - nebulised ipratropium bromide (anticholinergic) or IV aminophylline (same class as theophylline). Add magnesium sulfate if life threatening
What are features of life threatening asthma?
PEF less than 33%, sate less than 92, PaO2 less than 8kPa, PaCO2 greater than 4.5 kPa (greater than 6 requires mechanical ventilation), silent chest, cyanosis, feeble respiratory effort, hypotension, bradycardia, confusion, coma
