Duke PA Rheumatology Pharmacology
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| The safest initial approach to treat OA is to use __ | a simple oral analgesic such as acetaminophen (perhaps in conjunction with topical therapy
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| If pain relief with acetaminophen is inadequate for pain control in OA, __ | oral nonsteroidal anti-inflammatory drugs or intra-articular injections of hyaluronic acidlike products should be considered
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| __ may provide short-term pain relief in disease flares | Intra-articular corticosteroid injections
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| Alleviation of pain does not __ | alter the underlying disease
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| has been associated with decreased pain and improved quality of life | participation in arthritis self help courses taught by allied health professionals
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| One study found that __ were cost-effective and were associated with good clinical outcomes | monthly telephone communications with patients
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| the available evidence shows that __ does not increase the development of osteoarthritis | regular low-impact exercise of osteoarthritic joints
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| The goals of an exercise program are to __ | maintain range of motion, muscle strength and general health
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| All patients with osteoarthritis of the knee should be taught __ and should be encouraged to perform them every day | quadriceps-strengthening exercises
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| Patients with osteoarthritis who participate in an aerobic exercise program have been shown to have improved __ , compared with patients who only perform range-of-motion exercises | aerobic capacity and 50-ft walking times, as well as decreased depression and anxiety
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| Many patients with osteoarthritis of the hip and knee are more comfortable __ | wearing shoes with good shock-absorbing properties or orthoses.
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| The use of an appropriately selected __ can reduce hip loading by 20 to 30 percent | cane
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| At present, these supplements cannot be recommended for use in the treatment of osteoarthritis | glucosamine sulfate and chondroitin sulfate
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| The recognition that pain in osteoarthritis is not necessarily due to inflammation has led to an increased awareness of the role of __ in the treatment of this disease. | simple analgesics
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| The ACR guidelines emphasize the use of __ as first-line treatment for osteoarthritis of the hip and knee | acetaminophen
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| __ can be used for short periods to treat exacerbations of pain | Opioid-containing analgesics, including codeine and propoxyphene (Darvon)
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| These agents are not recommended for prolonged use because they cause constipation and increase the risk of falling, particularly in the elderly | Opioid-containing analgesics, including codeine and propoxyphene (Darvon)
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| In patients requiring NSAID therapy, concurrent use of __ may allow the NSAID dosage to be reduced, thereby limiting toxicity | acetaminophen
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| it is important to monitor renal and liver function when prescribing __ | NSAIDs
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| __, has been shown to be better than placebo in relieving the pain of osteoarthritis | Capsaicin (e.g., ArthriCare), a pepper-plant derivative
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| Patients with a painful flare of osteoarthritis of the knee may benefit from __ | intra-articular injection of a corticosteroid such as methylprednisolone (Medrol) or triamcinolone (Aristocort
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| When a joint is painful and swollen, short-term pain relief can be achieved with __ | aspiration of joint fluid followed by intra-articular injection of a corticosteroid
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| A joint should not be injected more than __ times in one year because of the possibility of cartilage damage from repeated injections | 3-4
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| Patients who require more than three or four injections per year to control symptoms are probably candidates for __ | surgical intervention
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| Patients with painful osteoarthritis of the hip may benefit from __ | intra-articular corticosteroid injections. These injections should be performed under fluoroscopic guidance
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| __ is a major nonstructural component of the synovial and cartilage extracellular matrix | Hyaluronic acid
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| In patients with osteoarthritis, the concentration and the molecular weight of __ are decreased | hyaluronic acid
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| Gout is caused by __ crystal deposition in tissues leading to arthritis, soft tissue masses (i.e., tophi), nephrolithiasis, and urate nephropathy | monosodium urate
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| First-line therapy for acute gout is __ or __, depending on comorbidities; | nonsteroidal anti-inflammatory drugs, corticosteroids
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| second line therapy for gout | colchicine
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| after the first attack of gout, modifiable risk factors should be addressed, these risk factors are | high-purine diet, alcohol use, obesity, diuretic therapy
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| __ therapy for gout is initiated after multiple attacks or after the development of tophi or urate nephrolithiasis | Urate-lowering
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| __ is the most common therapy for chronic gout | Allopurinol
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| __ agents are alternative therapies in patients with preserved renal function and no history of nephrolithiasis | Uricosuric
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| __ are infection; intravenous contrast media; acidosis; and rapid fluctuations in serum uric acid concentrations | Common triggers for acute gout
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| stopping or starting allopurinol | can cause a rapid fluctuations in serum uric acid concentrations, leading to acute gout
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| Occasionally, first line therapies for gout may need to be supplemented by __ | short-acting opioids such as hydrocodone (Hycodan) and oxycodone (Roxicodone).
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| About __ percent of persons who experience a gout attack will have another attack within 12 months | 60
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| nonpharmacologic treatment of __ should begin with the first gout attack and should initially focus on modifiable risk factors | hyperuricemia
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| __ is recommended for patients with more than two gouty attacks per year, in patients with tophi, and in patients with joint damage seen on a radiograph | Urate-lowering pharmacotherapy using a xanthine oxidase inhibitor or uricosuric agent
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| __ therapy should not commence until the acute phase of gout has completely resolved because fluctuations in serum uric acid levels will exacerbate the inflammatory process | Urate-lowering pharmacotherapy using a xanthine oxidase inhibitor or uricosuric agent
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| When initiating urate-lowering therapy, concurrent prophylaxis with __ has been shown to reduce the risk of flare-ups | low-dose colchicine (0.6 to 1.2 mg daily) for three to six months
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| __ is the first-line urate-lowering therapy | Allopurinol
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| Approximately 2 to 5 percent of patients taking allopurinol have __ and other adverse effects | minor rashes
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| Those intolerant of allopurinol may undergo desensitization or may take __ | oxypurinol (the active metabolite of allopurinol)
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| __ are second-line therapy for patients who are intolerant of allopurinol, or they may be used in combination with allopurinol in patients with refractory hyperuricemia | Uricosuric agents
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| __ is the uricosuric agent most often used in the United States | Probenecid
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| Uricosuric therapy is contraindicated in patients with a history of __ | nephrolithiasis and is ineffective in those with a creatinine clearance of less than 50 mL per minute (0.83 mL per second).
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| __ have uricosuric properties and may be useful adjunctive therapies for patients with gout, hypertension, and hyperlipidemia | Losartan (Cozaar) and fenofibrate (Tricor)
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| goals of treatment for gout | acute event treatment, prevention of further attacks
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| caused by overproduction ro underexcretion of uric acid | gout
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| __% of gout patients are underexcretors of uric acid | 90
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| humans lack the enzyme needed to break down __ | uric acid
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| treatment for acute gout attack | NSAIDs
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| FDA approved NSAIDs for use in acute gout attack | indomethacin, sulindac, naproxen
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| inexpensive NSAID with minimal side effects | ibuprofen
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| NSAID with least GI side effects | nabumetone
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| NSAID with least renal toxicity | suldinac, nabumetone
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| NSAID with greates ability to prevent uric acid from being reabsorbed (expensive) | diflunisal
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| NSAIDs are contraindicated in those with | peptic ulcer disease, anticoagulation
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| GI bleeding, ulcer development, perforationsRenal toxicityLiver dysfunctionEdema, hypertensionDiarrhea, constipation, indigestion, nauseaDizziness, headache, somnolence | NSAID AE's
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| if patient has monoarticular involvement with gout __ is the prefered treatment | intra-articular corticosteroid
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| Oral corticosteroids used for gout | prednisone
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| Used only when NSAIDs, colchicine are not effective | oral corticosteroids
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| IM corticosteroids used for doubt | triamcinolone acetonide, methylprednisolone
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| HyperglycemiaInsomnia, restlessnessIncreased appetitePeptic ulcer/ bleedingOsteoporosisGlaucomaEdemaImpaired wound healingMyopathy | corticosteroid AE's
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| Most beneficial if started within 36 hours of acute attack | colchicine
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| colchicine is contraindicated in patients with | moderate to severe renal or hepatic disease and severe cardiac disease
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| Reduces lactic acid production in leukocytesDecreases urate crystal depositionUrate crystals are formed in low-pH environmentsReduces phagocytosisDecreases inflammationDoes not have analgesic or uricosuric effects | Colchicine
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| Onset of action 12 hoursElimination via biliary and renal (20%) routesRequires renal dose adjustments | Colchicine
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| GI (80% of patients)Nausea, vomiting, diarrhea, abdominal painAlopeciaAnorexiaBone marrow suppressionMyopathyDeath (cardiac, renal) | Colchicine AE's
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| Should not be initiated during an acute gout attackFluctuations in uric acid levels increase inflammation during an acute attack | Chronic Gout Urate-lowering Therapy
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| Initiate 4-6 weeks after acute attack in patients with frequent attacks (>2/year) or those with complications | Chronic Gout Urate-lowering Therapy
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| biggest AE to look out for with allopurinol | skin rash
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| mechanism of action of probenecid | inhibits the tubular reabsorption of urate at the proximal convoluted tubule
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| HeadacheNausea, vomitingHypersensitivitySore gumsMyelosuppressionExacerbation of gout | Probenecid AE's
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| Kidney stonesCrCl < 50 ml/min ineffective | Probenecid contraindications
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| May be used while titrating urate-lowering therapy to prevent flare upsDose is one 0.6mg tablet daily Use for 3-6 months | Colchicine
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| considered first line for OA | acetaminophen
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| Hepatic toxicityRashRenal toxicity GI bleedingMyelosuppression | acetaminophen AE's
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| don't drink alcohol and take | acetaminophen
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| a thin layer of capsaicin must be applied __ times daily for effect | 3-4
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| results may take up to 2 weeks for | capsaicin
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| topical analgesic | methylsalicylate (icy hot, bengay)
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| topical NSAID | diclofenac gel
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| when using NSAIDs to decrease the risk of GI bleed __ may be used | Proton Pump Inhibitor
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| only COX-2 inhibitor left on the market | Celecoxib (Celebrex)
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| contraindication of Celocoxib | sulfonamide allergy
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| Headache, dizziness, insomniaEdemaGI upset (diarrhea, nausea, abdominal pain)Upper respiratory illnessBackache RashMI (<2%), CVA | Celecoxib AE's
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| COX-2 inhibitors that were withdrawn from the market | Vioxx, Bextra
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| if a patient is taking Celecoxib as well as aspirin or warfarin | the GI protective effect is erased
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| next step before going to controlled opioids | tramadol (ultram)
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| FlushingDizziness, headache, insomnia, somnolenceItchingConstipation, nausea, vomiting, GI upsetWeaknessOrthostatic hypotensionSeizureHallucinations | Tramadol AE's
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| Opioids are used for | those in severe pain, unable to tolerate NSAIDs or tramadol
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| Itching, rashConstipation, nausea, vomitingUrinary retentionRespiratory depression | Opioid AE's
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| if a person is constipated while on opioids use a | stimulant laxative
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| mush without a push | stool softener without a stimulant laxative with opioid use
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| Used for those with OA of the knee who have not responded to non-pharmacologic and analgesic treatments | intra-articular therapy
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| maximum of __ injections of glucocorticoids per year | 4
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| glucocorticoid injection effects last __ weeks | 4-8
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| Hyaluronic acid injection effects last up to __ months | 6
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| __ is administered by injection once weekly for 3-5 weeks | hyaluronic acid
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| Injection site (pain, swelling, bruising)Respiratory infection | hyaluronic acid injection AE's
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| when trying glucosamine or chondroitin, discontinue if no response after __ months of use | 6
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| limited oral absorption 0-13% | chondroitin
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| goals of treatment for RA | acute treatment of flare-ups, chronic disease-modifying treatment
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| disease modifying anti-rheumatic drugs | DMARDs
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| Initial treatment, bridge therapy for RA | NSAIDs
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| Should not be the sole treatment for RADo not alter the disease courseDo not prevent joint destruction,RA patients are twice as likely to have serious complications as OA patients | NSAIDs
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| Osteoporosis CV risk- weight gain, edema, HTN, atherosclerosisHyperglycemiaSkin fragilityGI bleedingCataractsCushing’s syndrome | long term AE's of Glucocorticoids when treating RA
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| if patients with RA are on more than 5mg of prednison daily they need | vitamin supplements-1500mg calcium, 400-800 IU vitamin D, bisphosphonates (age >65, h/o fracutre)
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| Should be initiated within 3 months of diagnosis of RA | DMARDs
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| Reduce and prevent joint damagePreserve joint integrity and functionReduce total healthcare costsMaintain economic productivity of patientwith RA | DMARDs
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| Gold standard DMARD | methotrexate
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| contraindications of methotrexate | pregnancy, severe renal or hepatic impairment
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| Nausea, vomiting, diarrhea, anorexiaAlopecia, rashMyelosuppressionLiver, renal failureHyperuricemiaOral ulcersCough, SOB (pulmonary fibrosis | methotrexate AE's
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| patients taking methotrexate should avoid | alcohol
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| patients taking methotrexate should also take __ as it reduces toxicity and GI effects | folic acid
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| elimination of this drug may take up to 2 years | leflunomide
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| Diarrhea (32%), weight loss (up to 20%)HTN (18%)Alopecia, rashElevated LFTsRespiratory tract infection | Leflunomide AE's
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| don't give this drug to premenopausal females if it can be helped | Leflunomide
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| Women AND men who wish to conceive must undergo __ washout when taking leflunomide | cholestyramine
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| Benefits shown in 1-6 monthsDoes not slow radiologic damageShould not be used as monotherapyBest tolerated DMARD200mg BID | Hydroxychloroquine
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| Nausea, vomiting, diarrheaMyopathyHeadache Disorder of cornea, retinopathy*AgranulocytosisSkin pigmentation | Hydroxychloroquine AE's
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| Onset of effect within 1-3 monthsSlows radiographic progression | Sulfasalazine
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| HeadachePhotosensitivity, rash*, yellow-orange discoloration*Nausea, vomiting, diarrhea, anorexiaMyelosuppressionLiver and kidney failureOligospermia* | Sulfasalazine AE's
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| Contraindications- active infections (TB skin test before initiating therapy), HF (infliximab | Anti-TNFα
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| very costly, but may be worth the cost due to efficacy | Anti-TNFα
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| Useful in those unable to tolerate TNF agentsContraindications- active infectionsDaily SQ injection | Anakinra
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| HeadacheInjection/Infusion site reactionRespiratory tract infection, rhinitisAbdominal pain, vomitingMyelosuppression | Anti-TNFα AE's
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