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