Week 4

Question 1

Joints commonly affected in osteoarthritis

Answer 1

• Hands (tips of fingers)
• Large weight bearing joints (hips, knees)

Question 2

In osteoarthritis are the joints effected symmetrically or asymmetrically?

Answer 2

• Either but usually asymmetrical

Question 3

In osteoarthritis are symptoms systemic or localized

Answer 3

localized

Question 4

What might would we expect to find in synovial fluid analysis in someone with osteoarthritis?

Answer 4

• Mild leukocytes

Question 5

How long do patients with osteoarthritis generally experience morning stiffness?

Answer 5

30 minutes

Question 6

What joints are commonly affected in RA?

Answer 6

• Fingers, toes, feet (GIP spared - happens in osteo)

Question 7

Does RA have systemic or local symptoms

Answer 7

Systemic

Question 8

Which lab value would we expect to see elevated in RA?

Answer 8

ESR (erythrocyte sedimentation rate)
- indicates inflammatory process in the body

Question 9

In RA, what might would we expect to find in synovial fluid?

Answer 9

• Leukocytes and cloudy

Question 10

How long do patients with RA generally experience morning stiffness?

Answer 10

• 60 minutes or more

Question 11

What are the goals of treatment for RA?

Answer 11

• Manage symptoms, prevent further joint damage, reduce pain and inflammation and stiffness, slow progression, maintain joint function and range of motion, minimize systemic involvement

Question 12

What are the typical pharmacologic treatments for RA?

Answer 12

• NSAIDS
• Glucocorticoids
• Prednisone
• Antimalarials (Planequil)
• DMARDS (disease modifying antirheumatic drugs)
• Conventional
• methotrexate
• Biological
• Adalimumab
• humira
• Targeted
• Tofactinib

Question 13

What baseline assessment and/or data needed before starting any DMARD?

Answer 13

• CBC
• TB
• Liver/renal function
• ALT/AST
• s/s infection
• skin assessment to check for malignancies
• rule out pregnancy

Question 14

We need baseline ophthalmologic and cardiac exam for which DMARD?

Answer 14

• Hydroxychloroquine

Question 15

What are the names of some conventional DMARDS?

Answer 15

• Methotrexate
• Leflunomide
• sulfasalazine
• hydroxychloroquine

Question 16

What are the names of some biologic DMARDS?

Answer 16

(Enbrel, humera)
* Adalimumab
* certolizumab

Question 17

What is the MOA of Methotrexate?

Answer 17

• Folate antagonist – inhibits DNA synthesis and cellular replication

-may be effective due to suppression of B and T lymphocytes

Question 18

Within how many months of RA diagnosis should Methotrexate be started and why?

Answer 18

• Within the first three months to help decrease further joint damage

Question 19

What routine monitoring is needed for Methotrexate?

Answer 19

• Routine liver and kidney function testing

Question 20

What blood level do we expect to see elevated in a patient with gout?

Answer 20

Uric Acid

Question 21

What is the first-line treatment(s) for acute gout?

Answer 21

• NSAIDS for less than 3 flares per year
• Colchicine
• corticosteriods

Question 22

What is the typical treatment regimen for chronic gout?

Answer 22

• Low dose colchicine
• Allopurinol
• Febuxostat
• Probenecid

Question 23

What is the MOA of Febuxostat?

Answer 23

• Inhibits xanthine oxidase to prevent the formation of uric acid

Question 24

What is the initial dosage of colchicine for acute gout?

Answer 24

• 1.2mg at first dose and then 0.6mg 1 hour later
• Daily dose not to exceed 1.2 mg (0.6mg 1-2x per day until flare resolves)

Question 25

What is required to diagnose Osteoporosis?

Answer 25

* DXA – neck of femur or spine * T-score less than -2.5 is osteoporosis OR T-score -1-2.5 (low bone mass) plus a 10-year probability of hip fx of 3% or more OR 10 year probability of another osteoporosis related fx of 20% or more (FRAX score)

Question 26

What is the most common fracture seen in Severe Osteoporosis?

Answer 26

* Hip and vertebrae

Question 27

What is the first-line treatment of osteoporosis?

Answer 27

* Bisphosphonate * Alendronate * Ibandronate (upright 60 minutes) * Risedronate * Zoledronic acid * Calcium & vitamin D

Question 28

What Pt education should we provide regarding Bisphosphonates?

Answer 28

* Swallow pill whole with a full glass of water and remain upright for 30-60 min after taking * Take first thing in the morning with nothing in the stomach except for water * Do not take vitamins/minerals/other meds within 1 hour of taking this medication as it can impede absorption * No eating within 30 minutes

Question 29

What are some potential adverse effects of Bisphosphonates?

Answer 29

* Esophagitis * Osteonecrosis of jaw and hip * Hip fractures

Question 30

What is the MOA of Bisphosphonates?

Answer 30

* Inhibit osteoclast activity and reduce bone resorption turnover

Question 31

What is the black box warning for Raloxifene?

Answer 31

* Increased risk of thrombolytic events venous (DVT, PE) and death from stroke in postmenopausal women with a risk for CAD

Question 32

When are Bisphosphonates contraindicated?

Answer 32

* Esophageal disorders that impede swallowing, patients that can’t stay upright for 30 minutes * Active upper GI problems * Creatinine below 30-35 * Low CA and vit D levels need to be corrected prior to starting

Question 33

What electrolyte imbalance are patients taking Denosumab at higher risk for?

Answer 33

* Calcium and magnesium

Question 34

What baseline data is needed before starting bisphosphonates, denosumab or raloxifene?

Answer 34

* DXA * Height * CA and vit D levels * Creatinine * Pregnancy * Densumab --> oral exam * Raloxifene – mammogram