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95 Cards in this Set
- Front
- Back
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Old ppl
physical |
stoop
head tilt backward hips knees elbows flexed dehydrated |
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internal old ppl
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down hepatic metab (phase I)
renal glucose metab albumin T3 production all down |
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old ppl
neorulogical changes |
decrease nerve cells
reflexes slower less stage III and IV sleep |
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sundowners syndrome
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get more agitated as sun goes down
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meds to watch in oldies
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antibiotics
ACh Diabetic H2 blockers sedatives |
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impair old ppl sense
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antibiotics
anticholinergics |
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cardiovascualr old ppl
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up systolic bp
down CO, SV HR takes longer return normal Meds: down HR- central alpha2 ag Ca channel blockers - verapamil>>>Diltiazem BB |
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respiratory old ppl
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less elasticity
down ciliary func meds- down resp: narcotics benzos |
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GI old ppl
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down saivary production
down motility Meds: opoids, antacid, antichol incrase motility: antidepress, antibiotics |
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Urine old
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down GFR...
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SEX old ppl diff
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male: down testosterone, down sperm
female: down estrogen, d breast tissue, u vaginitis, dryer canal HTNs and antidespresants down sex drive not age |
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musculoskeletal old ppl
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decrease muscle mass- (careful long acting injectables)
EPS bone loss since 20ish |
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watch for skin breakdown with...old ppl
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doxycycline
diuretics |
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pain
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treat it
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immunization
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flu every year
pneumoncoccal every 5 |
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abuse number for oldies
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1 800 96 abuse
888 |
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Osteoporosis
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most common bone disorder
skeletal disorder: up risk fracture compromise bone strength |
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Bone mineral density
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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 |
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central dual energy X ray absorptionartry
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DXA? DXR
gold stardard to get BMD |
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T scores....
Z scores |
T- for more intense cases
post menopausal women or men >55 for diagnosis z- i guess not so serious |
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Hip fractures
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men have u mortality rate after
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bone remodelling
how and by what chemicals |
resorption- PTH, RANKL
formation- estrogen, testosterone, calcitonin |
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primary osteoporosis
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type 1 - post menopausal, maybe before oophorectomey
type 2 - age related, >75 yo |
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2ndary osteo
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due to med or disease
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Diseases might cause osteoporisis
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Vit D def
RA CRF CLD (liver) diabetes |
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Meds might cuase osteo
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systemic corticosteroids
>5mg/d prednisone >3 months anticonvulsant intramuscular medroxy pregesterone furosemide, heparin, PPI, aluminum |
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Risk factors osteo
modifyable |
alcohol
smokin low excercise immobile d Ca d Vit D |
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risk factors oseto
nonmodify |
age
F race (white or asian) FH less estrogen low BMI |
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WHO's FRAX risk factor is
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10 yr probability of fractures
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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 |
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peripheral bone density test
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screening tool osteo
X ray absorptivitiy Quantitative computed tomography |
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central DXA...its DXA for earlier
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gold standard
DX! |
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T scores and meaning
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-1.0 or above normal
-1 -> -2.5 low bone mass -2.5 and below dx |
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Pharm agents types osteo
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absorptive
anabolic one other |
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antiresorptive
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Ca
Vit D Bisphosphonates estrogen agonist/antag estrogen or estrogen progestin therapy calcitonin |
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anabolic
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teriparatide
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other
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denosumab
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Ca osteo
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women after 50 - 1200mg elemental Ca
no reduction fracture risk |
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Vit D
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can be produced internally
for intstinal Ca absorb down fracture risk adult 800-1000 IU/day |
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bisphosphontes - FLA first line
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CI- hypocalcemia
MOA- inhib osteoclasts, long live blasts up BMD, decrease fractures |
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bisphosphonates
dosing SE |
theres a table
GI irritation visual disturb osteonecrosis of jaw Zoledronic- flu like symptoms, A-fib |
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SERMs
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prevent and treat osteo
CI if previous thromboembolic event up BMD vertebral and femoral neck down risk vertebral fractures SE- like birth control |
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osteo break!
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apparently i gotta watch rest of this one
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Risk factors for gout
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great male
age fat HTN HCTZ shellfish/ alcohol!!!!! uric acid lvl.... |
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presentations gout
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acute gouty arthritis- usually 1st MTP joint - podagra
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the rest of the clinical presentations of gout
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nephrolithiasis
gouty nephropathy tophi - Na urate deposits Sx- fever, pain, warmth, swelling, inflammation joints |
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progression in gout
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tissue deposits--> gout-->renal complications--> CV complications
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Tx goals gout
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get rid of attack
prevent complications avert further attack reverse comorbidities |
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therapy for gout
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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 |
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NSAID gout
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inhib prostiglandins
DOC acute attack if not CI -short acting, initiate ASAP SE- GI, d CrCL, u BP CI- active PUD, HF, renal impair |
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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 |
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Colchicine
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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 |
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Steroid gout
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anti inflamm
CI active systemic infections |
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Prophyaxis gout
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adherence poor
>= 2 attacks a year use prophylaxis overlap- NSAIDs/ colchicine |
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XO inhibitors
allopurinol |
block syn. uric acid
dont start during acute attack CI- concominant didanosine, caution renal or liver SE rash, GI upset |
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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 |
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Febuxostat
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also XO inhib
40 mg daily after 2 weeks can up 80 CI-azathioprine or mercaptopurine |
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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 |
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Sulfinpyrazone
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same as probenacid
200-400/day BID w/ food q week up to 400-800 / day monitor CDC CI- radiation/chemotherapy, hypersensitive to ASA |
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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 |
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additional gout adjuncts
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losartan
fenofibrate the whole cholesterol thing maybe |
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RA is
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swollen inflamed synovial membrane
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epidemy
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>in women by 6
joint pain, low grade fever hands and feet most common |
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labs
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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 |
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guidlines how many points u need for RA
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6
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evaluation RA
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disease activity score28---- <3.2 low
ACR 20/50/70 (number is reduction in symptoms) |
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ACR guidelines for DMARDs and disease
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Duration <6 months, 6-24 months, >24months
Activity - low, mod, high Prognostic factors- bone errosion factor, +ve RF, function limited, extrarticular disease |
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Disease Remission... classifed as
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treat to target-- absense of major sx
ACR/EULAR -tender and swollen joint counts (not counting feet) -C reactive protein - PtGA??? |
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Tx usually
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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 |
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Non bioligc DMARDs
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MTX, LEF, HQC, SSZ
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MTX
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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 |
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LEF
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inhib t cell pyrimidine biosynthesis
LD- 100mg x 3 days M- 20 mg /day possible 10mg CI- PREGO Monitor- CDC, LFT, ... |
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HCQ
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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 |
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SSZ
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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 |
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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 |
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Other biologics
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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 |
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Abatacept
how blah hahfsdafouhjidsasadfhp |
down regulate T cell activation
bind CD80, CD86 receptor on APC again infection malignancies |
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Rituximab
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bind CD20 antigen B cells lead to lysis
monitor CDC give steroid, APAP, antihistamine risk infusion rxn no IV push or bolus |
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Vaccinations and RA
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live not recommended w/ DMARDs
Rituximab and abatercept expspecilly nonlive >4 wks prior rituximab no live vaccines during for 3 months after abatercept |
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Biologics DONT USE THEM TOGETHER
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FYI fuckers
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osteporosis again
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yay
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ET/EPT
what is it when it used SE |
think birth control
only when everything else doesnt work |
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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 |
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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 |
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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 |
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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% |
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Osteo prevention women
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Bisphosphonates:
Alendronate, oral Ibandronate, Risedronate Raloxifen ET/EPT |
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osteo men tx
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Alendronate
Risendronate Zoledronic Acid Teriparatide |
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bisphos osteo general
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watch oral sx
esophagus issues renal dysfunct |
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Ca, Vit D
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try in diet if have to supplement both
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raloxifine general osteo
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post menaupasual w/ hx family breast cancer
avoid if blood clot worry |
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ET/EPT osteao general
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prevention only when everyhting else has failed i think
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Teriparatide osteo general
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T score < -3.5 its first lineish
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tx monitoring
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DXA baseline and
q 2 years |
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bisphoss dont forget look at that damn chart
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fuck em
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