GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 20, Exams of Nursing

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GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Absorption changes - CORRECT ANSWERS Iron, vitamin B12, antifungal and calcium are decreased with decreased stomach acid scretion Slower gastric emptying increases risk of ulceration from NSAIDS, bisphosphonates and Kcl tabs Most drugs are absorbed by passive diffusion without significant age related changes TD formulations require SQ fat layer to form drug reservoir for absorption (caution if cachectic) Distribution during aging - CORRECT ANSWERS Lipid-soluble meds (diazepam) have increased half life Highly albumin bound drugs (phenytoin) can have larger fraction of free (active) drug PGP (efflux transporter) decreases with aging, which can lead to higher brain concentrations of meds (opioids) Metabolism in aging - CORRECT ANSWERS Morphine and propranolol clearance are reduced because of reduction in first pass metabolism, similar to other drugs with high first pass metabolism Phase I (oxidative reactions by CYP450 enzymes) can change based on age, genetics, sex and other drugs Ativan, oxazepam, temazepam depend on phase II metabolism and are less affected by aging Excretion in aging - CORRECT ANSWERS Need to look at GFR (Cockcroft-Gault). Dabigatran, dofetilide, and xarelto are dosed on ABW and not IBW Some clinicians round Scr up to 1 mg/dL because older adults have lower muscle mass which produces less creatinine which could overestimate renal function (controversial) or using AdjBW if obese Pharmacodynamic changes: Increased sensitivity - CORRECT ANSWERS BDZ and opioids: increased sensitivity to CNS effects Antipsychotic and metoclopramide: EPS and tardive dyskinesia TCA, Alpha-blockers, anti-HTN: OH Warfarin: greater inhibition of synthesis of Vitamin K-dependent clotting factors, increased bleeding risk Nsaid: GI bleeding GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Anticholinergic agent : increased confusion, dry mouth, constipation Pharmacodynamic changes: Decreased sensitivity - CORRECT ANSWERS B blocker: downregulation of Beta-1 receptors (reduced effect) B agonist: Decreased response to inhaled beta agonist, require continuous /scheduled treatment instead of PRN Impaired homeostasis - CORRECT ANSWERS Diuretics, ACE: sodium and electrolytes Diuretics: hydration status Overuse of meds - CORRECT ANSWERS Unnecessary meds: GI, CNS agents, vitamins, minerals Underused meds - CORRECT ANSWERS Anticoagulant, statins, antihypertensive Withdrawal symptoms - CORRECT ANSWERS Antihypertensives, antidepressant, anxiolytic, pain meds BEERS criteria - CORRECT ANSWERS A list of medications that are generally considered inappropriate when given to elderly people anticholinergic, BDZ, sedative-hypnotics, older antipsychotic, hypoglycemic, NSAIDS, PPI Medication Appropriateness Index (MAI) - CORRECT ANSWERS questions to ask about each individual medication in there an indication is the med effective is the dose correct is the sig correct etc. Does no assess allergies, AE, or compliance GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Goals of Dementia - CORRECT ANSWERS Maintain function and cognition Nonpharm therapy for Alzheimer's dementia - CORRECT ANSWERS Education, physical and mental exercise, comorbid condition management, avoid alcohol and meds that worsen mentation Medical foods for dementia - CORRECT ANSWERS Caprylidene, L-methylfolate, omega 3 FA, EPA , Vitamin C, E, B6 and B12, selenium, folic acid Supports metabolic balance in brain, lipid imbalance, synaptic integrity Donepezil (Aricept) - CORRECT ANSWERS Start: 5 mg daily MD: 10 mg daily, up to 23 mg/day Acetylcholinesterase inhibitor (2D6 and 3A4 metabolism, 96% protein binding) Mild-moderate or moderate-severe AD Tabs or ODT Rivastigmine (Exelon) - CORRECT ANSWERS Start: 1.5 mg BID PO or 4.6 mg patch MD: 3-6 mg BID or 9.5 mg TD patch daily (up to 13.3 mg TD patch daily) Capsule, solution, TD patch Acetyl and butryryl cholinesterase inhibitor N/V/D are more intense than with other meds, skin rxn with patch Mild-severe AD and mild-moderate dementia with Parkinson disease Galantamine (Razadyne) - CORRECT ANSWERS Start: 4 mg BID or 8 mg ER QD MD: 8-12 mg BID or 8-24 mg ER QD Tabs, solution, ER capsules Competitive reversible acetylcholinesterase inhibitor and nicotine receptor modulator (2D6 and 3A4 metabolizer) Mild-moderate AD dementia, give with food Needs renal adjustment GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Memantine (Namenda) - CORRECT ANSWERS Start: 5 mg QD or 7 mg ER QD MD: 10 mg BID, 28 mg ER QD Tabs, Solution, ER capsules N-methyl-aspartate receptor antagonist that blocks glutamate transmission Moderate-severe AD, can use in combo with cholinesterase inhibitor Donepezil/memantine - CORRECT ANSWERS Start and max dose: 10/28 mg QD in evening ER capsule Acetylcholinesterase inhibitor and N-methyl aspartate receptor antagonist Use after stabilized on both agents separately Requires renal adjustment AE of cholinesterase inhibitors - CORRECT ANSWERS GI effects: n/v/d; increased risk of GI bleed CNS: HA, insomnia, dizziness Cardiac: bradycardia, OH, syncope (BEERS criteria as inappropriate for syncope patients) Genitourinary: incontinence Long term AE: anorexia, weight loss, falls, hip fracture, pacemaker placement AE of memantine - CORRECT ANSWERS agitation, urinary incontinence, insomnia, diarrhea, dizziness, confusion, headache Summary of guidelines for dementia - CORRECT ANSWERS Initiate CI in patients with mild- moderate AD no evidence of one agent being superior to another Titrate to MD as tolerated Can increase to Max dose if tolerated and MD no longer effective, but clinically meaningful improvement is unlikely Moderate-severe AD: use CI, memantine or both No benefit of combo therapy Memantine has no benefit in mild AD GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Therapy duration for dementia - CORRECT ANSWERS 3-6 months to evaluate for objective benefit Limited studies looking at efficacy for more than 1 year, but most patients are on med for years Choosing wisely criteria: evaluate at 12 weeks and stopping if goals of therapy aren't met Stop at advanced stage of disease, taper if on high dose due to risk of rebound agitation Disease modifying therapy for Alzheimer's disease: Anti-amyloid Mab (aducanumab) - CORRECT ANSWERS Accelerated approval for MCI/mild dementia, safety and efficacy in advance disease not studied Reduction in amyloid plaques noted, but no reduction in cognitive decline Q4week infusion, costs 56K/year ADR: CNS hemosiderosis, micro hemorrhage and edema of brain MRI of brain within 1 year prior to start required, additional MRI required if concerns for amyloid related imaging abnormality (headache, AMS, visual disturbance, nausea) Behavioral and psych symptoms of dementia (BPSD) - CORRECT ANSWERS As disease progresses from mild to moderate, behavioral and psych symptoms occur and can wane as disease progresses to severe Commonly peaks during late afternoon or early evening "sun downing" Symptoms of BPSD during disease progression - CORRECT ANSWERS Assessment scales of BPSD - CORRECT ANSWERS Rarely used in practice, but need to determine target behavior, occurrences, severity to determine treatment response Pain —> Tylenol scheduled Rule out delirium caused by medical condition Constipation —> scheduled bowel regimen Non Pharm treatment of BPSD (Cornerstone) - CORRECT ANSWERS Behavior is how they communicate of unmet need Eliminate triggers GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS stress urinary incontinence - CORRECT ANSWERS Loss of small amounts of urine with increased abdominal pressure (sneezing, coughing) Stress UI is more common in post menopausal women Caused by: alpha blockers such as prazosin decrease urethral sphincter tone Overflow urinary incontinence - CORRECT ANSWERS Loss of urine because of excessive bladder volume caused by outlet obstruction or an acontractile detrusor Post voidal residual is often high (>300 mL) indicating incomplete emptying Caused by: anticholinergic agents, CCB, opioids decrease detrusor muscle contractions functional urinary incontinence - CORRECT ANSWERS Inability to reach toilet because of mobility constraints Caused by: sedating drugs that cause confusion, diuretics increase voiding Mixed urinary incontinence - CORRECT ANSWERS UI that has more than one cause, usually stress and overactive bladder Lifestyle changes for UI - CORRECT ANSWERS Weight loss for patients with BMI > 25-30 Limit caffeine and alcohol Stop smoking Limit fluid intake before bed Stress incontinence - CORRECT ANSWERS Pelvic floor exercise (kegel exercise) are first line, may need biofeedback to teach pelvic floor exercises Pessaries (prosthetic vaginal insertion device) or bulking agent injections to help stress incontinence Urge incontinence - CORRECT ANSWERS Pelvic floor exercises in combo with meds for urge or mixed UI Bladder training to increase time between voiding in urge incontinence Peripheral tibial nerve stimulation or sacral neuromodulation techniques are third line after lifestyle and pharm treatment GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Other first line treatment choices for UI - CORRECT ANSWERS Scheduled and timed voiding for patients with dementia Prostatectomy in men or self catheter for sever me overflow incontinence Pharm treatment for urge or active bladder - CORRECT ANSWERS Antimuscarinics, B3 agonist, onabotulinumtoxin A Antimuscarinics agents (oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, darifenacin) - CORRECT ANSWERS Magnitude of efficacy is modest Strong anticholinergic effect (BEERS criteria) LA formulations preferred due to modest decreased SE profile B3 agonist (mirabegron) - CORRECT ANSWERS Minimal anticholinergic effect High cost Can be used with antimuscarinics if mono therapy fails Avoid in HTN Onabotulinumtoxin A (intradresur or injections) - CORRECT ANSWERS Prevents stimulation of detrusor muscle Need to perform self cath Pharm treatment for Stress urinary incontinence - CORRECT ANSWERS Alpha adrenergic agonists, topical estrogens, SNRI Alpha adrenergic agonists (pseudoephedrine, phenylephrine) - CORRECT ANSWERS Efficacy is limited Topical estrogen (conjugated estrogen vaginal cream or estradiol vaginal insert or ring) - CORRECT ANSWERS Use if other symptoms of estrogen deficiency Vaginal estrogens can improve severity of stress incontinence GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS SNRI (Duloxetine) - CORRECT ANSWERS Not FDA approved for stress urinary incontinence, but can reduce severity AE limit its usefulness Pharm treatment for overflow urinary incontinence - CORRECT ANSWERS Alpha adrenergic antagonist, 5 alpha reductase inhibitor, cholinomimetics, PDE 5 inhibitors Alpha adrenergic antagonist (alfuzosin, Tamsulosin, silodosin, doxazosin, terazosin, prazosin) - CORRECT ANSWERS AE vary dependent on selectivity to receptor in bladder or prostate (alfuzosin, silodosin, tamsulosin are more specific and preferred in older adults) 5 alpha reductase inhibitor (finadteride, dutasteride) - CORRECT ANSWERS Slows progression Reduces size of prostate and alters PSA values Cholinomimetics (Bethanechol) - CORRECT ANSWERS Stimulates detrusor muscle but also has systemic cholinomimetic effects PDE 5 inhibitor (tadalafil) - CORRECT ANSWERS 5 mg once daily approved for BPH Pharm treatment for functional urinary incontinence - CORRECT ANSWERS No drugs, consider potential interventions to remove any potential cause, barriers or obstacles; provide schedules or prompted toileting, assistance may be required to transfer on and off commode Pharm treatment for Mixed urinary incontinence - CORRECT ANSWERS Focus mainly on predominating symptoms, consider treatments for individual components (stress and urge) BPH epidemiology - CORRECT ANSWERS Usually develops after age 40, by age 60 more than 50% of men have it and by 85 90% of men have BPH Pathophysiology of BPH - CORRECT ANSWERS Type II 5 alpha reductase inhibitor facilitates conversion of testosterone to dihydrotestosterone, resulting in prostate growth GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS What is the approved dose of Tadalafil for BPH? - CORRECT ANSWERS Tadalafil 5 mg QD Where does phosphodiesterase induce smooth muscle relaxation? - CORRECT ANSWERS Bladder, urethra, and prostate Why is it not recommended to combine PDE5 inhibitors with alpha blockers? - CORRECT ANSWERS No studies showing effectiveness and risk of hypotension How can PDE5 inhibitors be used to treat both BPH and ED? - CORRECT ANSWERS If there is a 4-hour separation in doses What is the recommended therapy duration if Tadalafil is used concomitantly with finasteride for BPH? - CORRECT ANSWERS 26 weeks or fewer When is combination therapy in BPH recommended? - CORRECT ANSWERS May be needed in men with LUTS, large prostate size, and elevated PSA or in men with co-occurring symptoms of ED Which medications are best studied for combination therapy in BPH? - CORRECT ANSWERS Finasteride and doxazosin What is the FDA-approved combination for symptomatic men with an enlarged prostate? - CORRECT ANSWERS Dutasteride with tamsulosin What did the MTOPS and CombAT trials conclude about combination therapy in BPH? - CORRECT ANSWERS Men with LUTS and enlarged prostate can achieve further benefit using 2 drugs in combination When might alpha blockers be used with anticholinergic agents in BPH? - CORRECT ANSWERS For men with low PVR and irritative symptoms Saw palmetto plant extract for BPH (Serenoa repens) - CORRECT ANSWERS No benefit over placebo, conflicting evidence GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Using this agent with 5 alpha reductase inhibitor can reduce efficacy of reductase inhibitor B-sitosterol, Pygeum africanum show some benefit but short term studies Surgery in BPH - CORRECT ANSWERS Men with severe symptoms and in those with moderate symptoms who have not responded to medical treatment Anticholinergic agents in BPH - CORRECT ANSWERS Can be appropriate and effective alternative in men without elevated PVR when LUTS are predominantly storage (irritative) symptoms Terazosin - CORRECT ANSWERS 1-10 mg daily AE: OH Start at low dose, titrate every 2-7 days Start at bedtime Doxazosin - CORRECT ANSWERS 1-8 mg daily AE: OH Start at bedtime Start at low dose, titrate every 2-7 days Alfuzosin ER - CORRECT ANSWERS 10 mg daily AE: OH No need to titrate, take after meal Tamsulosin, modified release - CORRECT ANSWERS 0.4-0.8 mg daily AE: Can cause less orthostasis, causes ejaculatory dysfunction Start at bedtime Silodosin - CORRECT ANSWERS 8 mg daily (4 mg daily if CrCl 30-50) AE: Causes ejaculatory dysfunction, and is less sedating CI if CrCl < 30 GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Take with food Finasteride - CORRECT ANSWERS 5 mg daily AE: decreased libido Onset of action is 6 months Monitor PSA Category X pregnancy Dutasteride - CORRECT ANSWERS 0.5 mg daily AE: decreased libido Onset of action is 6 months Monitor PSA Category X pregnancy Dutasteride/tamsulosin - CORRECT ANSWERS 0.5/0.4 mg daily AE: decreased libido Onset of action is 6 months Monitor PSA Category X pregnancy Tadalafil - CORRECT ANSWERS 5 mg daily AE: OH Avoid use with alpha blockers No data in combination or with long term use Osteoarthritis - CORRECT ANSWERS OA is most prevalent form of arthritis Associated with aging (hip and knee most affected) Risk factors of OA - CORRECT ANSWERS Age, female, obesity, genetics, sports, occupation, previous injury, acromegaly, other chronic illness GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS What is the recommendation for using topical capsaicin for hand OA? - CORRECT ANSWERS Conditionally recommended against How often should topical capsaicin be dosed? - CORRECT ANSWERS Four times a day (QID) on a scheduled basis What precautions should be taken when administering topical capsaicin? - CORRECT ANSWERS Wear gloves, avoid contact with eyes, and do not skip doses What percentage of patients may experience local irritation when using topical capsaicin? - CORRECT ANSWERS 40% Intraocular glucocorticoid injections for OA - CORRECT ANSWERS Methylprednisolone or triamcinolone 10-40 mg injection dependent on size of joint, can be repeated every 3 months AE: risk of septic arthritis, synovitis Tylenol for OA - CORRECT ANSWERS Alternative to NSAID or when NSAID are contraindicated, very small effect size in clinical trials, few experienced benefit Max dose of 3 g/day in older adults Monitor for hepatotoxicity in patients with risk of liver disease with periodic LFT (consider lowering MDD to 2 g) Duloxetine for OA - CORRECT ANSWERS Majority of evidence in OA of knee, but conditionally recommended for OA of knee, hip or hand Used alone or with NSAIDS Concern about tolerability Diet supplements for OA - CORRECT ANSWERS ACR recommends against use of glucosamine-chondroitin supplements for relief of hips knee, but conditionally recommended for hand OA Chondroitin supplements not recommended for use in any OA Evidence to support use is contradictory, not many AE GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Opioids for OA - CORRECT ANSWERS Tramadol is a choice when nsaids are ineffective or contraindicated. Can be used for any OA Shouldn't use other opioids for OA but can be used if other non-opioid alternatives have been exhausted Epidemiology of RA - CORRECT ANSWERS Systemic disease characterized by bilateral inflammatory arthritis that affects small joints of hands, feet, wrist Up until age 60 it is more common in women, after age 60 prevalence is equal Can occur at any age but has increasing prevalence up to age 70 Autoimmune disease with strong genetic predisposition Pathophysiology of RA - CORRECT ANSWERS Chronic inflammation of the synovium leads to proliferation and development of a pannus Pannus invades joint cartilage and causes bone and joint destruction Cause of initial inflammatory activation is unknown, but once activated the immune system produces antibodies and cytokines that accelerate cartilage and joint destruction Clinical presentation of RA - CORRECT ANSWERS Joint pain, stiffness, fatigue and other inflammatory symptoms (warmth, redness, swelling of joints, with symmetrical distribution) Elevated RF, ESR, CRP, anti-cyclic citrullinated peptide antibodies, and normochromic normocytic anemia RA can also cause pulmonary fibrosis, vasculitis and dry eyes Therapy goals for RA - CORRECT ANSWERS Control inflammatory process so that disease remission occurs, leads to relief of pain, maintenance of function and increased QOL Response measured by: reduction in number of affected joints, and in joint tenderness and swelling, improvement in pain, decreased amount of morning stiffness, reduction in inflammatory markers, QOL improvement Non pharm treatment of RA (concurrent with pharm treatment) - CORRECT ANSWERS Rest during periods of disease exacerbation, OT and PT, maintain normal weight to reduce stress on joints, assistive devices, surgery for tendons or joints if needed GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS DMARDs for RA - CORRECT ANSWERS Start dmard within 3 months of diagnosis (MTX preferred) Step down approach: start with DMARD (1+ depending on severity) together with anti- inflammatory (NSAID or steroid). As pain is controlled, reduce anti-inflammatory agent. As joint damage and inflammation is controlled, reduce DMARD slowly. Do not stop all DMARDs even if patient is in remission Which nonbiologic DMARD is considered first-line for RA? - CORRECT ANSWERS MTX has the most long-term data and best outcomes. Which nonbiologic DMARD has a slow onset of action? - CORRECT ANSWERS Hydroxychloroquine. Which nonbiologic DMARD is the drug of choice in pregnancy for RA? - CORRECT ANSWERS Sulfasalazine. Which nonbiologic DMARD can be substituted with efficacy comparable to MTX? - CORRECT ANSWERS Leflunomide. What are some poor prognostic factors in RA that may indicate the need for combo DMARD therapy? - CORRECT ANSWERS Functional limitation, extra-articular disease, positive RF, anti-cyclic citrullinated peptide antibodies, or bony erosions on radiography. When are biologic DMARDs used for RA? - CORRECT ANSWERS Biologic DMARDs are used in combo with MTX for severe disease or as alternatives if nonbiological DMARDs are ineffective or contraindicated TNF inhibitors for RA - CORRECT ANSWERS Etanercept (common), infliximab (common), adalimumab, certolizumab, golimumab Non TNF biologics for RA - CORRECT ANSWERS Abatacept (common), anakinra, rituximab (common), tocilizumab, sarilumab Biologic kinase inhibitors for RA - CORRECT ANSWERS Tofacitinib, baricitinib, upadactinib GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Monitor for infection Golimumab (Simponi), TNF inhibitor - CORRECT ANSWERS 50 mg SQ every month Mab against TNF Intended for use in combo with MTX Monitor for infection Abatacept (Orencia), non TNF biologic - CORRECT ANSWERS Weight based dose at 0,2 and 4 weeks then monthly (750 my for those weighing 60-100 kg) Inhibit interactions between antigens and T cells, can be useful in those who don't respond to TNF inhibitors Monitor for infusion reactions Anakinra (Kineret), non TNF biologics - CORRECT ANSWERS 100 mg SQ daily IL-1 receptor antagonist, avoid combo with TNF Agnes's because of increased infection risk Rituximab (Rituxan), non TNF biologic - CORRECT ANSWERS 2 infusions of 1 g 2 weeks apart Chimeric antibody to CD20 protein on B lymphocytes, corticosteroid infusions to help reduce infusion reaction, used in combo with MTX to improve response Sarilumab (Kevzara), non TNF biologic - CORRECT ANSWERS 200 mg SQ once every 2 weeks IL-6 receptor antagonist Can use as mono therapy or in combo with Nonbiologic DMARDs Should not be used with biologic DMARDs Don't start if ANC <2 K/mm^3, platelet <150 K/mm^3, or AST/ALT > 1.5 x ULN Tocilizumab (Actemra), non TNF biologic - CORRECT ANSWERS 4 mg/kg IV infusion every 4 weeks, can increase to 8 mg/kg on basis of clinical response Anti human IL6 refiero Mab; indicated for patients who have not responded to TNF inhibitors Monitor for infections GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Barcitinib (Olumiant), Kinase inhibitor - CORRECT ANSWERS 2 mg daily Oral janus kinase inhibitor Can be used as monotherapy or in combo with MTX or other nonbiologic DMARDs Not recommended for use with biologic DMARDs or potent immunosuppressants (azathioprine, cyclosporine) Don't start with lymphocytes < 500 cells/mm^3, ANC < 1000 cells/mm^3 or Hgb < 8 mg/dL Tofacitinib (Xeljanz), Kinase inhibitor - CORRECT ANSWERS 5 mg BID Oral Janus Kinase inhibitor (2nd line therapy) Monotherapy or in combo with MTX Upadactinib (Rinvoq) - CORRECT ANSWERS 15 mg daily Oral Janus kinase inhibitor Can be used as monotherapy or in combo with MTX or other nonbiologic DMARDs Not recommended to be used with biologic DMARDs or potent immunosuppressants Don't start with lymphocytes < 500 cells/mm^3, ANC < 1000 cells/mm^3 or Hgb < 8 mg/dL Malignancy in RA - CORRECT ANSWERS More common, GI cancers and lymphoproliferative disorders. Melanoma and lung cancer risks were elevated Use DMARDs over biologics in melanoma; use rituximab over TNF inhibitors in lymphoproliferative disorders Osteporosis in RA - CORRECT ANSWERS More common Calcium and VIt D recommended, start bisphosphonate for prevention if prednisone 5 mg+/daily is prescribed Gout (monosodium urate crystal deposition disease) - CORRECT ANSWERS A spectrum of clinical and pathologic features caused by hyperuricemia (serum urate concentrations more than 6.8 mg/dL), resulting in tissue deposition of monosodium urate monohydrate crystals in the extracellular fluid of joints and other sites Gout primary symptoms - CORRECT ANSWERS acute intermittent episodes of synovitis presenting with joint swelling, pain called acute gout flares GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Diagnosis of gout - CORRECT ANSWERS Presents as acute episodic arthritis Can present as chronic arthritis of 1+ joints, especially if prolonged hyperuricemia exists Tophi can be present Uric acid nephrolithiasis and chronic nephropathy Acute gout attack features - CORRECT ANSWERS Severe pain, redness, swelling (max severity in 12-24 hours) can continue for few days to several weeks Most often affects lower extremities in single joint (Frist metatarophalangeal joint) or knee Can occur in other joints including upper extremity joints Can be polyarticular at first presentation How is gout definitively diagnosed? - CORRECT ANSWERS Ideally through joint aspiration of crystals, with needle-shaped or rod-shaped crystals being diagnostic of gout. What makes diagnosing gout challenging during an acute attack? - CORRECT ANSWERS Joint aspiration can be difficult due to pain, and serum uric acid levels can be low during flares. It's best to check uric acid levels 2 weeks after a flare. What are some easier ways to diagnose gout? - CORRECT ANSWERS Gout can be diagnosed based on clinical presentation and hyperuricemia. Diet factors predisposing to gout - CORRECT ANSWERS High meat, seafood consumption, fatty foods, overindulgent diet, high intake of beer and spirits (not wine) in men, sugar sweetened soft drinks and high fructose foods Drug factors predisposing to gout - CORRECT ANSWERS Xanthine oxidase inhibitors, uricosuric agents (with initial therapy), thiazides and loops, niacin, calcineurin inhibitor low dose ASA (< 325 mg/day) Medical conditions predisposing to gout - CORRECT ANSWERS Obesity, DM, HTN, HLD, metabolic syndrome, CHF, organ transplant, CKD, early menopause, trauma, surgery, starvation, dehydration, episodic alcohol consumption GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS What is the dosing of Colchicine for patients on dialysis during an acute gout attack? - CORRECT ANSWERS 0.6 mg x1, do not repeat treatment more than every 2 weeks How should dosing of Colchicine be adjusted if hepatic/renal impairment is noted during an acute gout attack? - CORRECT ANSWERS Concomitant use of PGP or 3A4 is contraindicated, adjust dose if drug-drug interaction is noted but no impairment What is the initial dose of Naproxen during an acute gout attack? - CORRECT ANSWERS What is the dose of Naproxen during an acute gout attack? - CORRECT ANSWERS 750 mg initially, then 250 mg every 8 hours What is the dosing regimen for Naproxen ER during an acute gout attack? - CORRECT ANSWERS 1000-1500 mg QD followed by 1000 mg QD What is the dosing regimen for Indomethacin during an acute gout attack? - CORRECT ANSWERS 50 mg TID until pain is resolved then reduce dose until attack resolves What is the dosing regimen for Sulindac during an acute gout attack? - CORRECT ANSWERS 200 mg BID How should the dosing of other NSAIDs be adjusted during an acute gout attack? - CORRECT ANSWERS Use analgesic dosing, same as for treatment of acute pain When should the full dose of NSAIDs be continued during an acute gout attack? - CORRECT ANSWERS Until the attack completely resolves When can the dose of NSAIDs be tapered during an acute gout attack? - CORRECT ANSWERS If comorbidities or hepatic impairment are present Celecoxib (Celebrex) during acute gout attack - CORRECT ANSWERS 800 mg x1 then 400 mg on D1 then 400 mg BID for 1 week Only to be used in certain patients when NSAIDs are contraindicated or not tolerated GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS What are the recommended glucocorticoid options for treating an acute gout attack? - CORRECT ANSWERS Prednisone 0.5 mg/kg per day for 5-10 days or Prednisone 0.5 mg/kg per day for 2-5 days, then taper for 7-10 days, then discontinue or Methylprednisolone dose pack How can glucocorticoids be administered for acute gout attacks affecting 1 or 2 large joints? - CORRECT ANSWERS Intra-articular corticosteroids with dose based on joint size (e.g., triamcinolone 40 mg for large joint, 30 mg for medium joint, 10 mg for small joint or equivalent) Can be used in combo with COS, NSAID or colchicine What is the recommended treatment for acute gout attacks in cases where intra-articular corticosteroids are not suitable? - CORRECT ANSWERS IM triamcinolone 60 mg, followed by oral glucocorticoid Colchicine (colcrys) for acute gout attack prophylaxis - CORRECT ANSWERS 0.6 mg QD or BID (MDD 1.2 mg) CrCl 30-80: monitor for AE, no adjustment necessary CrCl < 30: initial dose 0.3 mg/day, use caution and monitor dose if titrated further Dialysis: 0.3 mg twice weekly, monitor for AE Severe hepatic impairment: consider dose reduction, don't repeat course more often than every 2 weeks NSAIDS for acute gout attack prophylaxis - CORRECT ANSWERS Lower doses than used for acute attacks (Naproxen 250 mg BID or Indomethacin 25 mg BID) Consider concomitant PPI or other agent for PUD suppression if needed PO glucocorticoids - CORRECT ANSWERS Prednisone or prednisolone < 10 mg daily Consider if colchicine/NSAIDs can't be used Management of Hyperuricemia (Chronic ULT) - CORRECT ANSWERS Stop meds that cause hyperuricemia GERIATRICS EXAM QUESTIONS AND CORRECT DETAILED ANSWERS ,A COMPLETE SOLUTION THAT COVERS 2024/2025 BEST RATED TO SCORE A+ FOR SUCCESS Indications for chronic ULT: 1+ SQ tophi on clinical exam or imaging, 2+ acute gout attacks/year, radiographic damage as result of gout First line treatment for chronic ULT - CORRECT ANSWERS Xanthine oxidase inhibitors (XOI) Allopurinol preferred for 1st line agent for all patients, including those with moderate-severe stage 3 CKD Start at low dose < 100 mg/day) with titration to target serum urate over starting at higher dose Change to alternative XOI (febuxostat) in patients not responding to first XOI Alternative to XOI for chronic ULT - CORRECT ANSWERS Probenecid Uricosuric if atleast 1+ XOI is not working Hx of urolithiasis and CrCl < 50 limit use of probenecid Increased urinary uric acid indicates uric acid overproduction and is contraindication to use of uricosuric ULT Add-on therapy for Chronic ULT: Lesinurad - CORRECT ANSWERS Selective uric acid reabsorption inhibitor Only used as add-on to allopurinol or febuxostat in those who do not achieve target uric acid concetrations Last line therapy for Chronic ULT therapy: Pegloticase - CORRECT ANSWERS If goal serum acid not achieved, stop other therapies and use only Pegloticase Not recommended as first line therapy in any case When should anti-inflammatory prophylaxis be started for acute gout? - CORRECT ANSWERS Concomitantly with or just before ULT in all patients What can cause an early increase in acute gout attacks during ULT start? - CORRECT ANSWERS Rapid decrease in urate concentrations, resulting in remodeling of articular urate crystal deposits