Exam 4 - Unit 3 - Musculoskeletal

:Skeletal tissue include

CT, nerves, and blood vessels

Functions of musculoskeletal system

Support body frame
Store minerals & lipids
Produce blood cells
Protect internal organs
Leverage for movement

These cells promote bone
formation

Osteoblast

These cells promote bone
resorption

Osteoclast

This is defined as low bone mass

Osteopenia

This dysfunction in defined as low bone mass, micro architectural disruption, & increased skeletal fragility resulting in decreased bone strength & increased risk of fracture

Osteoporosis

Risk factors for osteoporosis include age, gender, race, diet, lack of exercise, alcohol intake, & long term steroid therapy. What type of screening can be done to confirm this?

Bone mineral density (BMD) scan

What ways can someone prevent osteoporosis?

Eliminate modifiable risk factors, exercise, calcium & vitamin D

Who are candidates for treatment of osteoporosis?

Postmenopausal women or men >50yrs w/: history of
hip
fracture & high risk for fracture

Hormonal agents include:

Calcitonin & Raloxifene

This is a selective estrogen receptor modulator that acts like agonist in bone to prevent bone loss

Raloxifene MOA
SE: hot flashes, edema, increases risk of VTE & stroke

Raloxifene is used in patients with a low risk of VTE & a high risk for which type of cancer?

Breast cancer

These inhibit osteoclast formation which decreases bone resorption

Bisphosphonates
-Alendronate, risedronate, ibandronate, & zoledronate

Bisphosphonates are
first line
for which dysfunction?

Osteoporosis
Must
be taken with a
full
glass of water & sit upright for
>30min
AND until first meal of the day to prevent esophageal irritation

Side effects of bisphosphonates include:

Severe bone pain, GI irritation, hypocalcemia, osteonecrosis of jaw

These are monoclonal antibodies that inhibit osteoclast formation. Side effects include GI upset, skeletal pain, infections, hypocalcemia & osteonecrosis of the jaw

Rank Ligand inhibitor

What are the clinical uses for Rank Ligand inhibitors?

Osteoporosis treatment in men OR postmenopausal women if bisphosphonate therapy isn't appropriate

These are recombinant formulations of endogenous parathyroid hormone that stimulate osteoblast function & GI & renal calcium absorption

Anabolic agents

Anabolic agents are used for _____ osteoporosis or when there was a _____ on another agent. These should not exceed a _____ year duration and ______ should be initiated after completion.

Severe; failure; two; bisphosphonates

What is the black box warning for anabolic agents?

Risk of osteosarcoma

This is a systemic autoimmune condition characterized by inflammation at the joints. Symptoms fluctuate and can affect the tendons, ligaments, and skeletal muscles

Rheumatoid arthritis

Treatment goals for RA include:

Preventing joint damage and loss of function
Control pain
Maintain quality of life

These are an eclectic group of medications used to control inflammation

Disease modifying anti rheumatic drugs (DMARDs)
Methotrexate
Sulfasalazine
Hydroxychloroquine

This drug modulates local chemical mediators of the inflammatory response. Is used as an add on therapy to methotrexate.

DMARD: sulfasalazine

This drug has an unclear MOA, is an add on therapy to methotrexate

DMARD: hydroxychloroquine

These drugs elevate TNF levels in synovial fluid, are involved in pathologic pain & joint destruction. End result is reduction of cytokine driven inflammatory process

Tumor Necrosis Factor inhibitors
Step up from methotrexate & add on

Boxed warnings for TNF inhibitors include:

Infections & malignancy

The following are Non-TNF inhibitors

Abatacept, rituximab, tocilizumab

This drug is a T cell modulator. Side effects include anemia, headache, nausea and infusion reactions

Non-TNF inhibitors: Abatacept

This drug is a B cell mediator. Side effects include infusion reactions, mucocutaneous reactions, &
progressive multifocal leukoencephalopathy
&
Cardiac toxicity (BW)

Non-TNF inhibitors:Rituximab

This drug is an IL-6 inhibitor (reduction in cytokine & acute phase reactant production.) Side effects include
infections/TB (BW)
hepatotoxicity, & hyperlipidemia

Non-TNF inhibitors: Tocilizumab

These drugs are cyclooxyrgenase inhibitors and are used adjunct for inflammation & pain control

NSAIDs

This drug has no inflammatory effects but is used adjunct for pain control. Side effects include hepatotoxicity

Acetaminophen

This dysfunction is characterized by monosodium rate crystal deposition with accumulation surrounding the joints, recurrent flares of inflammatory arthritis and chronic arthralgia.

Gout
Overproduction / underexcretion of uric acid

What are the triggers for gout?

Alcohol, diet, stress, illness, & diuretics.
T: uric acid <6mg/dL, prevent flares

Treatment options for gout

Allopurinol:
1st line
. PGX testing for HLA-B 5801
Febuxostat: those who can't tolerate allopurinol.
cardiovascular toxicity (BW)

Medications used for gout prevention

Colchicine, NSAIDs, oral glucocorticoids.
Duration lasts 3-12 months
after
achieving uric acid levels are reached

This preventative drug prevents activation, degranulation, and migration of neutrophils associated with mediating some gout symptoms

Colchicine

Some CNS conditions are associated with abnormally high reflex activity in the neuronal pathways that control skeletal muscle. Goals of therapy for this condition is to reduce spasticity and pain

Muscle spasms

Skeletal muscle relaxants are

Cyclobenzaprine
Methocarbamol
Short term/intermittent use

MOA for this drug is a centrally acting skeletal muscle relaxant and reduction of tonic somatic motor activity. Side effects include anticholinergic effects and CNS depression

Cyclobenzaprine

MOA for this drug is a CNS depressant.

Methocarbamol

This muscle relaxant works of GABA to inhibit the transmission of both monosynaptic and polysynaptic reflexes at the spinal cord level

Baclofen
SE:
Withdrawal (BW)
, CNS depression
CU: chronic spasticity following spinal cord injury

Other skeletal muscle relaxants

Diazepam, gabapentin, pregabalin, tizanidine

Skeletal muscle relaxants includes high risk when combine with which drugs?

Opioids & benzodiazepine. Exposure should be minimized as much as possible