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32 Cards in this Set

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Rheumatoid Arthritis (RA)

Definition
chronic autoimmune disorder
unknown etiology
symmetric, erosive synovitis
may extend to extra-articular sites
RA

presentation
- onset - rapid to slow
- course
-10-20% short w/remission
-70-80% mild to mod w/exacerbations
-10-20% progressively destructive
- hallmark SX - morning stiffness
RA

pathophys
immune system attack cells in joints causing synovitis (warmth, reddness, swelling, pain)

cells of synovium grow and divide abnormally during inflammatory process causing synovium to become thick
RA

Drug Tx
DMARDs (dz mod anti rheumatic drugs)
NSAIDs
Low-Dose oral CS

utilize aggressive TX w/DMARDs first is most popular - "inverted pyramid"
- w/ or w/out NSAID

NSAIDS - should not be considered a sole treatment option
RA

DMARDs - The players (list)
hydroxychloroquine (Plaquenil)
sulfasalazine (Azulfidine)
methotrexate (Rheumatrex)
gold Na thiomalate (Myochrysine)
auranofin (Ridaura)
azathioprine (Imuran)
penicillamine (Cuprimine)
minocycline (Minocin)
leflunomide (Arava)
etanercept (Enbrel)
infliximab (Remicade)
anakinra (Kineret)
adalimumab (Humira)
RA

aspirin and other NSAIDS

moa
prevents prostaglandin formation by inhibiting cyclooxygenase

antithrombotic effect of ASA occurs by irreversible (unique to ASA) inhibition of platelet cyclooxygenase (others reversi)

ASA - inflammatory effect 3-5g/day
RA

What can be done to avoid complications when pt on chronic NSAIDS?
dec risk of GI ulceration
- histamine blocker (ranitidine)
- PPI - lansoprazole only PPI FDA-appr
for prevention of NSAID-induce ulcer
-mosoprostol (oral prostaglandin analog)
- available in combo with diclofenac
(Arthrotec)
COX 1 Vs COX 2
COX 1
- found in most tissues that produce
prostaglandins (PGI1 and PGI2 -which
protect the gastric barrier)

COX 2
- present at sites of inflammation
RA

Drug TX - COX 2 inhibitor
celocoxib - Celebrex
- inhibits prostaglandin syn via COX 2
- black box - CV and GI risk
- lower incidence of GI lesions than
ibuprofen, naproxen, diclofenac
- except when take w/low dose ASA
RA

DMARD TX principles
- reduce or prevent joint damage and
preserve joint integrity and function
- initiate DMARD TX w/in 3 months
- even if adequate treatment w/NSAID
- Methotrexate typical initial tx
- track record to induce long respons
- DMARDs lose function over time
- rare for pt to use one med for > 2 yrs
RA

DMARDs - qw or longer doing
methotrexate (Rheumatrex)
- qw; PO, IM, SC, IV
gold Na thiomalate (Myochrysine)
- q2-4w; IM
etanercept (Enbrel)
- qw; SC
infliximab (Remicade)
- w2,4,6, then q8w; IV
adalimumab (Humira)
- qow; SC
RA

DMARDs- qd to tid dosing
hydroxychloroquine (Plaquenil)
sulfasalazine (Azulfidine)
auranofin (Ridaura)
azathioprine (Imuran)
penicillamine (Cuprimine)
minocycline (Minocin)
leflunomide (Arava)
anakinra (Kineret)
RA

nondrug tx
Prosorba column - removes inflammatory antibodies from pts blood

Joint surgery

mild exercise
diet - increase daily protein intake
support group
Osteoarthritis (OA)

definition
aka degenerative joint disease (DJD)

affects the weight-bearing joints of the peripheral and axial skeleton

60-80% > 65yo
OA

presentation
-pain worsens w/weight-bearing acty
-changes in weather influence pain
-joint/morning stiffness common
-different from RA
- < 30 min
- resolves w/movement
-joint deformities
- Herberden's and Bouchard's nodes
- osteophytes on the DIP and PIP jnts
OA

pathophys
???
affects cartilage (thins) so cant dissipate force of normal weight-bearing acty
OA

treatment principles
-focuses on sx control
-pain relief is primary treatment

hip
-APAP is first
-add NSAID next
-then opioid analgesic

knee (above plus)
- intraocular steroid inj
- topical analgesics
- capsaicin and methylsalicylates
Gout

definition
systemic dz caoused by build-up of uric acid in the joints
- causes inlammation, swelling, pain
- hyperuricemia - > 8mg/dL males >7f
Gout

presentation
-pain in one joint of lower extremity
-initial period of pain self-limiting
- then period w/no SX
-intercritical periods (times b/w attacks)
- 3m to 2y
- shortens as dz progresses
-knee, ankle, heel, wrist, finger, elbow
-may experience fever chills mailaise
-untreated lasts 1=2 weeks
Gout

pathophys
primary gout
- uric acid overproducers
- uric acid underexcreters

acute gout attacks caused by deposition of monoNa urate crystals (MSU) in the synovium of the joint
- results in stim of inflam cascade
- sharp crystals damage leukocytes
- causes them to spew contents
- results in inflammatory reaction
Gout

treatment goals
-relieve pain and inflammation

- reduce serum uric acid

- prevent recurrent attacks
Gout

Drug TX - three treatments for acute attacks
1. colchicine
2. NSIDs (indomethacin mainly)
3. CSs
Gout

colchicine
-colchicine
-anti-inflam but no analgesic atcy
- inhibits leukocytes from gulping up
urate crystals
-never exceed 8mg during acute attack
-0.6 to 1.2mg po q2h until
- pain relief achieved
- or diarrhea ocurs
- works best if start w/in 12-36h of onset
of attack
gout

indomethicin
is effective at any point during an attack
gout

corticosteroids
given intra-articularly, IV or PO

limited to treatment failure w/colchicine and NSAIDs
Gout

prophylaxis
low dose colchicine (0.6-1.2mg/d)

treatment depends on whether pt is an overproduce or underexcreter

excrete > 600 = overproducer
Gout

prophylaxis - underexcreters
uricosurics
- probenecid (Benemid)
- sulfinpyrazone (Anturane)
- promote excretion of uric acid
- drink > 2L/water/d to dec uric acid
stone formation
- never begin uricosuric tx during attack
- since uricosuric tx may precipitate an
attack - take cholchisine or NSAIDs for
first 6-12 months
Gout

prophylaxis - over producers
xanthine oxidase inhibotor
- xanthine a precursoer in uric acid syn
- allopurinol (Zyloprim)
- immediately report any rash
- qd dosing
NSAIDs

acetic acids
diclofenac (Voltaren, XR) qd-bid
etodolac (Lodine, XL) qd-bid
indomethacin (Incodin, SR) qd-bid
nabumetone (Relafen) qd-bid
tolmetin (Tolectin)
sulindac (Clinoril)
which NSAIDs can be taken by route other than PO?
diclofenac (Vlotaren) PO, Ophth

indomethacin (Indocin) PO, IV, supp
NSAIDs

propionic acids
fenoprofen (Nalfon)
flubiprofen (Ansaid)
ibuprofen (Motrin)
ketoprofen (Orudis, SR) - QD
naproxen (Naproxyn)
oxaprozin (Daypro) - QD
NSAIDs

others
fenamates
meclofenamate (Meclomen)

oxicams
piroxicam (Feldene) - QD

cox-2 selective
celocoxib (Celebrex)