EMQs in Clinical Medicine.pdf - Peshawar Medical College

Disease-modifying anti-rheumatic drugs (DMARDs) – answers 135
H
B
C
G
An 80-year-old man with a 30-year history of rheumatoid arthritis
presents to A&E with fever and pain in the right knee. On examination
his right knee is red, hot and swollen. Aspirated synovial fluid is frankly
purulent.
Aspiration of the joint and culture is required to establish whether the
acutely swollen knee has resulted from inflammation, infection or a crystal
arthropathy. Intravenous flucloxacillin plus benzylpenicillin is also a popular
drug combination that is used until sensitivities have been established.
A 65-year-old woman recently diagnosed with osteoarthritis requires
medication for joint pain.
Paracetamol should be prescribed before NSAIDs for relief of
osteoarthritic pain. The use of NSAIDs for analgesia can be problematic
in a chronic condition such as osteoarthritis as a result of the risk of
gastrointestinal bleeding with long-term use.
A 64-year-old woman who has been successfully treated for acute
gout requires prophylactic medication.
Colchicine is an alternative to NSAIDs in an acute presentation of gout
in patients in whom NSAIDs are contraindicated, e.g. those with allergy
or heart failure. Allopurinol is a xanthine oxidase inhibitor that
decreases the production of uric acid and is used only for prophylaxis.
It should not be used in treatment of acute gout and, in fact, its use may
actually provoke acute gout during that period.
A 65-year-old woman with polymyalgia rheumatica.
Oral prednisolone is the treatment of choice for polymyalgia rheumatica.
53 Disease-modifying anti-rheumatic drugs (DMARDs)
Answers: H B C K E
H
B
CT of patient on long-term DMARD treatment shows pulmonary and
hepatic fibrosis.
Methotrexate is also indicated in the treatment of malignant disease and
severe psoriasis unresponsive to conventional therapy. Methotrexate can
show cumulative toxicity and so renal and liver function tests should be
carried out every 2–3 months while on treatment (monitor weekly until
therapy is stabilized). Other examples of drugs causing pulmonary fibrosis
are bleomycin, amiodarone and nitrofurantoin.
Fertility testing reveals oligospermia in a 48-year-old man on DMARD
treatment.
Sulfasalazine (sulphasalazine) is known to cause a reversible oligospermia
in up to 70 per cent of males treated for over 3 years.