Rheumatoid Arthritis and Osteoarthritis: Diagnosis, Treatment, and Medication Management, Exams of Nursing

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NURS 565 Midterm Exam 2024Questions with

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When prescribing Medications, we must understand that the liver function declines with age d/t what? Enlarged Liver Decreased blood flow to liver Increased activity of the hepatic enzymes - Correct Answer B. Decreased blood flow to liver An 82 yo male visits the clinic complaining that his pain meds "take forever" to work after he takes his pill. What are possible reasons you can explain to him as to why this may be happening. Perhaps we need to increase your dose Sometimes as you get older, absorption may be slower resulting in a delayed response As we get older, the gastric acid decreases and may delay absorption - Correct Answer B. Sometimes as you get older, absorption may be slower resulting in a delayed response As we get older, the gastric acid decreases and may delay absorption RA Characteristics Onset Affected population Location Joint stiffness duration SxS - Correct Answer weeks-months women>men common hands, feet, & wrists

60 min in AM local & sys. OA Characteristics Onset Affected population Location Joint stiffness duration SxS - Correct Answer years men & Women equally Hands & weight baring joints

<30min in AM typically local What might you expect to find in the synovial fluid of a pt with OA - Correct Answer Mild leukocytes What might you expect to find in the synovial fluid of a pt with RA - Correct Answer Cloudy with leukocytes Goals of Tx for RA - Correct Answer Sxs relief (pain, stiffness, inflammation, maintaining joint fxn and ROM minimize systemic involvement delay progression Typical pharm Txs for RA - Correct Answer NSAIDs, systemic steroids, antimalarials, antimetabolites, and biologics Baseline assessment data before starting DMARD - Correct Answer Liver, PG, serum creatinine, CBC with diff, sxs of infxn (TB & hepatits), Hx & physical, renal status, & malignancies Significant baseline data for Sulfasalazine - Correct Answer CXR, pulmonary and neuro status Significant baseline data for Leflunomide - Correct Answer CXR, BP & pulmonary status Significant baseline data for Mehtotrexate - Correct Answer CXR, Pulmonary and GI status Significant baseline data for hydroxychloroquine - Correct Answer Ophthalmologic & cardiac exam (ECG if indicated) Conventional DMARDs- examples - Correct Answer Methotrexate, hydroxychloroquine, sulfsalazine Biologic DMARDS- examples - Correct Answer adalimumab, etanercept, golimumab "-mab"s MOA of methotrexate - Correct Answer folic acid antagonist ->inhibits lymphocyte proliferation Within how many months of RA diagnosis should Methotrexate be started and why?

• Correct Answer 3 months of diagnosis

delay joint degeneration What routine monitoring is needed for Methotrexate? - Correct Answer Periodic liver & renal fxn What blood level do we expect to see elevated in a patient with gout? - Correct Answer Uric acid First line Tx for gout - Correct Answer Corticosteroids, NSAIDs, or Colchicine What is the typical treatment regimen for chronic gout? - Correct Answer Allopurinol, Febuxostat, low dose Colchicine (prophylaxis) MOA of febuxostat - Correct Answer inhibits xanthine oxidase ->decreased production of uric acid Is allopurinol safe to use with patient who have renal dysfunction? - Correct Answer Yes; Rx of choice for pts with renal dysfxn or who overproduce uric acid What is the initial dosage of colchicine for acute gout? - Correct Answer 0.6mg TID on 1st day OR 1.2mg x 1 -> 0.6mgx1 in 1 hour; on subsequent days, 1-2/day until flare resolution What is required to diagnose Osteoporosis? - Correct Answer DXA scan T score of -2.5 or lower T score of -1 to -2.5 PLUS one of the following: 10yr prob. of hip Frx of 3% or more OR 10 yr prob of osteoperosis r/t frx of 20% or more What is the most common fracture seen in Severe Osteoporosis? - Correct Answer Hip & Vertebrae What is the first-line treatment of osteoporosis? - Correct Answer Bisphosphonates with calcium and vitamin D supplementation. Bisphophosphonates- examples - Correct Answer Alendronate, ibandronate, risedronate, zolendronic acid "-dronate" "-dron-"

Pt education for bisphosphonates - Correct Answer Swallow tab whole take with full glass of H2O remain upright for at least 30min (60min for ibandronate) Take medication on empty stomach Possible AEs of bisphosphonates - Correct Answer Esophagitis, osteonecrosis of the jaw, & hip frx MOA of bisphosphonates - Correct Answer Inhibits osteoclast bone resorption Black box warning for Raloxifene - Correct Answer Increased risk for VTE Increased risk for death from stroke in PM women with Hx or risk of CAD Bisphosphonates' contraindications - Correct Answer esophageal disorders CrCl < 30/ml/min inability to sit or stand for <30 min Active upper GI problems low Ca and vit D lvls What electrolyte imbalance are patients taking Denosumab at higher risk for? - Correct Answer Ca & Mag What baseline data is needed before starting bisphosphonates, denosumab or raloxifene? - Correct Answer DXA, Ca & Vit D lvls, PG status Denosumab: oral exam Raloxifene: mammogram Bisphosphonates: Creat & renal fxn What are the first-line options for hypertension? - Correct Answer TZD, ACEI, ARB What are first-line antihypertensives for African Americans? - Correct Answer TZD or CBB What antihypertensive classes are recommended for patients with CKD or HF? - Correct Answer ACEI or ARB Women who have hypertension and osteoporosis should be prescribed which antihypertensive medication? - Correct Answer TZD What should we monitor for when a patient is prescribed an ACEI and K+ sparing diuretic? - Correct Answer Hyperkalemia

What are some potential side effects of Statins? - Correct Answer Myopathy Myalgia (check CPK) GI upset What should patients avoid taking with simvastatin or lovastatin? - Correct Answer Grapefruit Macrolides Schedule 1 drugs (description) - Correct Answer No acceptable medical use High abuse & dependance potential Schedule 1 drugs - Correct Answer Heroin LSD Cannabis MDMA Peyote Schedule 2 drugs (description) - Correct Answer High dependence & abuse potential. considered dangerous BUT have purpose Schedule 2 drugs - Correct Answer Rx with <15mg of hydrocodone (vicodin) cocaine Meth methadone hydromorphone oxy fentanyl Adderall Ritalin Schedule 3 drugs (description) - Correct Answer low-mod dependence potential less than class 1&2 but more than 4 Schedule 3 drugs - Correct Answer Rx with <90mg of codeine(Tylenol and codeine) Ketamine Anabolic steroids Testosterone Schedule 4 drugs (Description) - Correct Answer low dependence & abuse potential Schedule 4 drugs - Correct Answer Xanax Ativan Soma

Darvocet Valium Tramadol An 82 year old male visits the clinic complaining that his pain medications "take forever" to work after he takes his pill. What are possible reasons you can explain to him? Perhaps we need to increase your dosage. Sometimes as you get older, absorption may be slower resulting in a delayed response. As we get older the gastric acid decreases and may slow absorption. - Correct Answer B. Sometimes as you get older, absorption may be slower resulting in a delayed response. As we get older the gastric acid decreases and may slow absorption. Distribution of medication can be affected in the elderly in what ways? Decreased hormones Increased body fat Decreased lean mass Decreased albumin - Correct Answer B. Increased body fat C. Decreased lean mass D. Decreased albumin When prescribing medications, we must understand that liver function declines with age due to what cause? Enlarged liver Decreased blood flow to liver Increased activity of the hepatic enzymes - Correct Answer B. Decreased blood flow to liver What is the most important cause of Adverse Drug Reactions? High drug dosages Lack of monitoring of medications Decreased renal excretion Overprescribing/Polypharmacy - Correct Answer C. Decreased renal excretion What can a poor metabolism phenotype do to metabolism of drugs? - Correct Answer Reduced or absent enzyme activity which can lead to slow processing of meds (low effect) or increased risk of SEs.

How does poor metabolism affect a high or low therapeutic index? - Correct Answer Some Rx need to be converted to active form for use -> low therapeutic effect Some Rx need to be metabolized for clearance ->risk for OD BB warning for opioids - Correct Answer Resp arrest BB warning for Fentanyl - Correct Answer Fatal Resp Depression BB warning for Methadone - Correct Answer QT prolongation Fatal dysrhythmias (Torsades) Resp Dep BB warning for Codeine - Correct Answer 10% codeine -> morphine in liver Poss. Death in children severe toxicity risk in BF infants BB warning for Hydromorphone and Oxymorphone - Correct Answer HIGH ABUSE POTENTIAL Resp dep esp. when used with other sedatives i.e. alcohol BB warning for Oxycodone - Correct Answer High abuse potential Resp dep. What are therapeutic uses for morphine? - Correct Answer Pain, sedation, euphoria, resp depression, cough suppression, suppression of GI motility, reduces anxiety What are therapeutic uses for Fentanyl? - Correct Answer •Chronic pain (PATCHES), acute pain, cancer pain When should a patient be referred to a pain specialist? - Correct Answer 120mme/day What is MME and when to use it? - Correct Answer Morphine milligram equivalent Potency of an opioid ID opioid prescription burden of a single person What is the PDMP and when to use it? - Correct Answer Prescription drug monitoring program Used when prescribing controlled substances How to assess someone for possible drug diversion - Correct Answer UA screen PDMP routine use

Risk Factors for OUD? - Correct Answer Family hx of abuse personal hx of abuse cross tolerance mental illness When to prescribe Naloxone? - Correct Answer With every opioid prescription Drugs not safe to take with opioids? - Correct Answer Opioids, alcohol, antihistamines, CNS depressants, or general anesthetics Provider Responsibilities when Prescribing opioids? - Correct Answer 12 CDC guidelines 12 CDC guidelines when prescribing opioids - Correct Answer 1. Opioids are NOT 1st line

2. est. goals for pain & Fxn
3. discuss risks and benefits
4. Use IR to start
5. lowest effective dose
6. prescribe short durations for acute pain
7. eval. benefits and harm frequently
8. Use strats to mitigate risk
9. Review PDMP data
10. us UA testing
11. avoid concurrent opioid and Benzo prescribing
12. offer tx for OUD In what patient population are statins contraindicated? - Correct Answer Pregnant women pts with viral or ROH hepatitis CAUTION: pts taking fenofibrates or zetia In what patient population is Warfarin contraindicated? - Correct Answer PG or lactating severe thrombocytopenia or uncontrollable bleeding lumbar puncture regional anesthesia eye, brain, or spinal surgery, CAUTION: hemophilia, increased capillary permeability, dissecting aneurysm, GA ulcers, hypertension, women anticipating abortion What patient population needs a lower dose of warfarin? - Correct Answer Elderly, renal, and hepatic

What BP medications are okay to use during pregnancy? - Correct Answer Labetalol, nifedipine Statins can have potentiating AE from which inhibitor? - Correct Answer 3A4: Can increase levels of lovastatin and simvastatin Furosemide can have a drug-drug interaction with what medications? - Correct Answer Digoxin-increases risk of toxicity and dysrhythmias Gentamycin- ototoxicity What are some medications for treatment of angina? - Correct Answer Nitrates- decrease O2 demand and dilating veins->decreased preload Beta-blockers decrease O2 demand by decreasing HR and contractility CCB- arterial dilation (decreased afterload) decreases HR and contractility Ranolazine- POSSIBILY by helping myocardium generate energy more efficiently Contraindications for ranolazine? - Correct Answer Existing QT prolongation or taking Rx that increase QT. Hepatic impairment or 3A4 inhibition A 41 year old patient comes into the clinic complaining of increased heart rate after starting Nitro patches for stable angina. What would an appropriate response be? Lets lower the dose and frequency of use I will prescribe a beta blocker to help with this Next time this happens, lie down and practice deep breathing, this will bring your heart rate down. - Correct Answer B. I will prescribe a beta blocker to help with this Role of aldosterone? - Correct Answer Retention of Na and excretion of K and H leading to increased volume. Promotes remodeling and fibrosis through SNS activation and decreasing uptake of NE in heart Promotes vascular fibrosis decreasing arterial compliance and disrupting baroreceptor reflex How to mitigate adverse effects of aldosterone? - Correct Answer Antagonist (eperlonone)- block receptors ->increased retention of K and increased excretion of Na and H A patient with HF develops fibrotic changes, what should the provider do next? - Correct Answer Prescribe an ARB- inhibits fibrosis

HTN Guidelines according to Rosenthal and Burchum - Correct Answer Diuretics, Beta blocker, RAAS inhibitor (ACEI, ARB, aldosterone agonist), CCB For the general population what class of HTN medication is appropriate? - Correct Answer Thiazide diuretics For a CKD patient, what class of HTN is appropriate? - Correct Answer ACEI or ARB For the African American patient, what class of HTN medication is appropriate? - Correct Answer Diuretics->CCB, & A/B blockers When are ACEI contraindicated - Correct Answer 2nd & 3rd trimester PG Bilateral renal artery stenosis When are CCBs contraindicated? - Correct Answer HTN, sick sinus syndrome, 2nd or 3rd degree heart block When are Beta Blockers contraindicated? - Correct Answer Bradycardia, AV heart block CAUTION: Pts with HF, asthma, bronchospasm, DM, hx of severe allergic Rxns What clinical tools are used to treat hyperlipidemia? - Correct Answer Lifestyle changes, DASH diet, increase dietary soluble fiber, exercise, wt loss, smoking cessation A 55 year old male comes into the clinic with a gouty arthritis. He states that he has one flareup a year. Your response is: I will prescribe you glucocorticoids to help with inflammation Lets start you on a prophylactic therapy of colchicine. It will be helpful to take an NSAID to start with to help relieve some inflammation. Ill prescribe Naproxen. - Correct Answer C. It will be helpful to take an NSAID to start with to help relieve some inflammation. Ill prescribe Naproxen. A patient comes in stating that he tried NSAIDS to relieve a gouty attack but it just hasn't helped. He asks, "what are my options?" He further states that he has attacks every few years but when he does NSADIS "never help." Your response is: I can prescribe a glucocorticoid (Prednisone) and that will bring down the inflammation/pain. Have you tried increasing your dosage of NSAIDS and drink plenty of water? Lets start by making some changes in your diet, can you tell me what you eat regularly? - Correct Answer A. I can prescribe a glucocorticoid (Prednisone) and that will bring down the inflammation/pain.

Colchicine is considered for long-term treatment if a person has _____ or more gouty attacks per year. - Correct Answer 3 (greater than 2) Colchicine should not be taken with what medications? - Correct Answer Statins, PGP inhibitors, 3A4 inhibitors Match the adverse affect to the proper medication Colchicine Allopurinol Probenecid Take with food to minimize GI side effects and drink 2.5-3L of water to prevent uric acid crystal formation in kidneys B. Nausea, vomiting, diarrhea, myelosuppression, and Myopathy C. SCAR can develop, generally well tolerated with minimal GI and neurologic effects - Correct Answer Colchicine-B Allopurinol-C Probenecid-A What should be co-administered with febuxostat? - Correct Answer NSAID or Colchicine for up to 6 mo after starting Lesinurad should be combined with what other gout medication? - Correct Answer Allopurinol- decreases uric acid levels in blood when Allopurinol alone did not work Initiation of Allopurinol can elicit an acute gouty attack. What can be taken in conjunction to prevent that? - Correct Answer Colchicine & NSAIDs (low dose) Adverse Effects of Colchicine? - Correct Answer GI myelosuppression or injury to proliferating cells (leukopenia, granulocytopenia, thrombocytopenia, and pancytopenia Myopathy or Rhabdo (long term tx) CAUTION: Statins Complications of untreated gout? - Correct Answer Erosion Irreversible joint dmg Renal dmg topn Allopurinol can cause what condition when taken long-term? - Correct Answer Hypersensitivity syndrome- rash fever eosinophellia, liver & kidney fxn

SCAR

Pt Education of Alendronate? - Correct Answer Swallow tab whole with glass of H2O, Remain upright for at least 30-60 min Take on empty stomach Take in AM before anything else is consumed Denosumab adverse effects? - Correct Answer Hypocalcemia infxns skin reactions osteonecrosis of jaw Match the med with the appropriate description: Ibandronate Alendronate Raloxifene 1st-line treatment of Osteoporosis Do not take with calcium, magnesium, or iron DVT, PE, and risk of stroke - Correct Answer Ibandronate- B Alendronate- A Raloxifene- C Baseline data for ALL DMARDS? - Correct Answer Complete Hx and physical Baseline diagnostics for ALL DMARDS? - Correct Answer CBC with diff WBC sxs of infxn assess for TB, hepatitis, malignancies, PG, ALT, AST, and serum Creat. DMARDS Pt Teaching - Correct Answer Risk for infxn avoid close contact with communicable dz seek medical attention for signs of infxn, bruising, bleeding, pallor, fatigue, fever, sxs of HF (SOB, orthopnea, fatigue, edema)