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95 Cards in this Set

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Old ppl
physical
stoop
head tilt backward
hips knees elbows flexed
dehydrated
internal old ppl
down hepatic metab (phase I)

renal

glucose metab

albumin

T3 production all down
old ppl
neorulogical changes
decrease nerve cells

reflexes slower

less stage III and IV sleep
sundowners syndrome
get more agitated as sun goes down
meds to watch in oldies
antibiotics

ACh

Diabetic

H2 blockers

sedatives
impair old ppl sense
antibiotics

anticholinergics
cardiovascualr old ppl
up systolic bp

down CO, SV

HR takes longer return normal

Meds: down HR- central alpha2 ag
Ca channel blockers - verapamil>>>Diltiazem
BB
respiratory old ppl
less elasticity

down ciliary func

meds- down resp:
narcotics
benzos
GI old ppl
down saivary production

down motility

Meds: opoids, antacid, antichol

incrase motility: antidepress, antibiotics
Urine old
down GFR...
SEX old ppl diff
male: down testosterone, down sperm

female: down estrogen, d breast tissue, u vaginitis, dryer canal

HTNs and antidespresants down sex drive not age
musculoskeletal old ppl
decrease muscle mass- (careful long acting injectables)

EPS

bone loss since 20ish
watch for skin breakdown with...old ppl
doxycycline

diuretics
pain
treat it
immunization
flu every year

pneumoncoccal every 5
abuse number for oldies
1 800 96 abuse

888
Osteoporosis
most common bone disorder

skeletal disorder:
up risk fracture
compromise bone strength
Bone mineral density
most common measure

depends peak bone mass, bone loss

women and menopause

gram of mineral/ area volume

at femoral neck and total hip
lumbar spine >2
distal 1/3 radius
central dual energy X ray absorptionartry
DXA? DXR

gold stardard to get BMD
T scores....
Z scores
T- for more intense cases
post menopausal women or men >55 for diagnosis

z- i guess not so serious
Hip fractures
men have u mortality rate after
bone remodelling
how and by what chemicals
resorption- PTH, RANKL

formation- estrogen, testosterone, calcitonin
primary osteoporosis
type 1 - post menopausal, maybe before oophorectomey

type 2 - age related, >75 yo
2ndary osteo
due to med or disease
Diseases might cause osteoporisis
Vit D def
RA
CRF
CLD (liver)
diabetes
Meds might cuase osteo
systemic corticosteroids
>5mg/d prednisone >3 months
anticonvulsant
intramuscular medroxy pregesterone
furosemide, heparin, PPI, aluminum
Risk factors osteo
modifyable
alcohol
smokin
low excercise
immobile
d Ca
d Vit D
risk factors oseto
nonmodify
age
F
race (white or asian)
FH
less estrogen
low BMI
WHO's FRAX risk factor is
10 yr probability of fractures
fractures...
kinds gen info
no warning first

vertebra- 2/3 asymp, sign d hieght, kyphosia, lordosis (curved spine top bottom respet)

hip- most serious

wrist- usually when young
peripheral bone density test
screening tool osteo

X ray absorptivitiy

Quantitative computed tomography
central DXA...its DXA for earlier
gold standard

DX!
T scores and meaning
-1.0 or above normal

-1 -> -2.5 low bone mass

-2.5 and below dx
Pharm agents types osteo
absorptive

anabolic

one other
antiresorptive
Ca

Vit D

Bisphosphonates

estrogen agonist/antag

estrogen or estrogen progestin therapy

calcitonin
anabolic
teriparatide
other
denosumab
Ca osteo
women after 50 - 1200mg elemental Ca

no reduction fracture risk
Vit D
can be produced internally

for intstinal Ca absorb

down fracture risk

adult 800-1000 IU/day
bisphosphontes - FLA first line
CI- hypocalcemia

MOA- inhib osteoclasts, long live blasts

up BMD, decrease fractures
bisphosphonates
dosing
SE
theres a table

GI irritation

visual disturb

osteonecrosis of jaw

Zoledronic- flu like symptoms, A-fib
SERMs
prevent and treat osteo

CI if previous thromboembolic event

up BMD vertebral and femoral neck

down risk vertebral fractures

SE- like birth control
osteo break!
apparently i gotta watch rest of this one
Risk factors for gout
great male
age
fat
HTN
HCTZ
shellfish/ alcohol!!!!!
uric acid lvl....
presentations gout
acute gouty arthritis- usually 1st MTP joint - podagra
the rest of the clinical presentations of gout
nephrolithiasis

gouty nephropathy

tophi - Na urate deposits

Sx- fever, pain, warmth, swelling, inflammation joints
progression in gout
tissue deposits--> gout-->renal complications--> CV complications
Tx goals gout
get rid of attack

prevent complications

avert further attack

reverse comorbidities
therapy for gout
NSAIDs
<48 h - colchicine

if so
1 joint - I.A. corticosteroid (if joint accessible

>1 joint - systemic corticosteroids (parental or oral)

if steroid CI then analgesics +- colchicine
NSAID gout
inhib prostiglandins

DOC acute attack if not CI
-short acting, initiate ASAP

SE- GI, d CrCL, u BP

CI- active PUD, HF, renal impair
NSAIDs gout
which ones
doses?
Indomethacin
25-50 QID 3 days, then BID 4-7 days

Naproxen 500 mg BID, 3 days then 250-500 qd 4-7 days

Sulindac 200mg BID 7-10 days
Colchicine
interupt deposition urate crystals

if NSAIDs inadequate

SE NnV, myelosuppression (long term use)

1.2 PO at first sign the 0.6 mg 1 hour later

d dose if 3A4 inhib

CI hepatic failure, renal weak, cardio issues
Steroid gout
anti inflamm

CI active systemic infections
Prophyaxis gout
adherence poor

>= 2 attacks a year use prophylaxis

overlap- NSAIDs/ colchicine
XO inhibitors
allopurinol
block syn. uric acid

dont start during acute attack

CI- concominant didanosine, caution renal or liver

SE rash, GI upset
allopurinol dose
how adjust
50-100 mg/day up by 50-100 q few weeks

target- uric acid < 6 mg/dL

if CrCl <30 ---<200mg
Febuxostat
also XO inhib

40 mg daily after 2 weeks can up 80

CI-azathioprine or mercaptopurine
uricosuric agents
probenacid
inhib reabsorption urate @ PRT

ONLY if documented underexcreter

250 BID for 1 wk then 500 BID max 2000

CI salicylates

after acute attack
Sulfinpyrazone
same as probenacid

200-400/day BID w/ food
q week up to 400-800 / day

monitor CDC

CI- radiation/chemotherapy, hypersensitive to ASA
Recombinant Uricase
Pegloticase
recombinant uricase uric acid - allantion

refractory pt only

8 mg IV infuse over 2 h q 2 weeks

must monitor for infusion rxn

given w/ antiH or corticosteroids

CI G6PD deficient
additional gout adjuncts
losartan

fenofibrate

the whole cholesterol thing maybe
RA is
swollen inflamed synovial membrane
epidemy
>in women by 6

joint pain, low grade fever

hands and feet most common
labs
Rheumatoid Factor (serological)

Anti citrullinated protein antibodies (ACPA) (serological)

C reactive protein (<0.8 mg/dL) (acute phase reactants)

erythrocyte sedimenation rate (ESR) - normal 20-30 (APR)

also CBC, LTF, stool, synovial fluid
guidlines how many points u need for RA
6
evaluation RA
disease activity score28---- <3.2 low

ACR 20/50/70 (number is reduction in symptoms)
ACR guidelines for DMARDs and disease
Duration <6 months, 6-24 months, >24months

Activity - low, mod, high

Prognostic factors- bone errosion factor, +ve RF, function limited, extrarticular disease
Disease Remission... classifed as
treat to target-- absense of major sx

ACR/EULAR
-tender and swollen joint counts (not counting feet)
-C reactive protein
- PtGA???
Tx usually
DMARD w/i 3 month dx
-NSAID / steroids symptom relief

Order DMARD
MTX/LEF 1st line
MTX- add TNF alpha very effective

biologics can be more effective than nonbiologics

steroids - interim only basically
Non bioligc DMARDs
MTX, LEF, HQC, SSZ
MTX
inhib cytokine production, purine syn
DOC

10-15 PO, SQ, IM q week
up 5 q 2-3 wks max 20-30

CI PREGO!!!!, severe liver disease

monitor- CDC, liver
LEF
inhib t cell pyrimidine biosynthesis

LD- 100mg x 3 days
M- 20 mg /day possible 10mg

CI- PREGO

Monitor- CDC, LFT, ...
HCQ
antimalaria

not w/ poor prognostic factors!
for low disease activity
<24 months

400-600 PO daily 4-12 wks
M-200-400 daily

6 wks til benfit

CI visual changes

monitor CDC, eye exams
SSZ
immunomodulatory and antiinflam

all durations, all activites
w/o poor prognostic factors

500-1g/ day daily/BID
M 1g PO BID max 3

CI salicylates
SE GI upset, rash SJ, urine discolor
Biological DMARDs
tnf aplhas inhib
TNF alpha inhibs- mod - severe

-Etanercept- 50 / wk SQ

-Infliximab- 3mg/kg at 0,2,6 wk then q 8 wks, IV WITH MTX

-Adalimumab- 40 mg q everyother wk, SQ


SE-serious infections BBW- do ppd and such
careful- HF and malignancies
Other biologics
Abatacept- <60 kg:500 60-100:750 >100:1000
IV or SC
mod- severe

Rituximab- 1000mg twice 0, 2 wks then q 24wks
IV infuse
mod-severe w/ MTX after fail w/ TNF alphas
Abatacept
how blah hahfsdafouhjidsasadfhp
down regulate T cell activation

bind CD80, CD86 receptor on APC

again infection malignancies
Rituximab
bind CD20 antigen B cells lead to lysis

monitor CDC

give steroid, APAP, antihistamine
risk infusion rxn
no IV push or bolus
Vaccinations and RA
live not recommended w/ DMARDs

Rituximab and abatercept expspecilly
nonlive >4 wks prior rituximab

no live vaccines during for 3 months after abatercept
Biologics DONT USE THEM TOGETHER
FYI fuckers
osteporosis again
yay
ET/EPT
what is it
when it used
SE
think birth control

only when everything else doesnt work
Calcitonin
when, who
name
does
Miacalcin inject or NS

only 5 years after menopause

inhib bone resorption
only for spine

only if cant tolerate other agents
Teriparatide
how long
watch for
tx what
no more than 2 yr

watch osteosarcoma

tx high fracture risk (T <-3.5)
also glucocorticoid induced

decrease vertebral and nonvertebral fracture risk and up BMD vertebra
Donsumab
tx who
how?
dose?
do what first
postmenopausal w/ high fracture risk

binds RANKL decrease osteoclast work

60 SQ q6 month

decrease fracture risk, up BMD at most sites

correct hypocalcemia first
Manage oseto?
generally when
hx hip or spinal fracture

T score -2.5 or lower

T score -1.0 to -2.5 and....FRAX
fracture >20%, hip >3%
Osteo prevention women
Bisphosphonates:
Alendronate, oral Ibandronate, Risedronate

Raloxifen

ET/EPT
osteo men tx
Alendronate
Risendronate

Zoledronic Acid

Teriparatide
bisphos osteo general
watch oral sx

esophagus issues

renal dysfunct
Ca, Vit D
try in diet if have to supplement both
raloxifine general osteo
post menaupasual w/ hx family breast cancer

avoid if blood clot worry
ET/EPT osteao general
prevention only when everyhting else has failed i think
Teriparatide osteo general
T score < -3.5 its first lineish
tx monitoring
DXA baseline and

q 2 years
bisphoss dont forget look at that damn chart
fuck em