NSG 533 ADVANCED PHARMACOLOGY EXAM QUESTIONS
AND ANSWERS LATEST UPDATE
BONE AND JOINT DISORDERS
What is the typical presentation of Osteoarthritis and the overall goals of
therapy?
Patients are usually more than 50 years old. May be asymptomatic to severe joint pain
and stiffness. Joint involvement is asymmetric. Inflammation is absent or mild. Cardinal
s/s are use-related joint pain (deep and aching), joint stiffness (abates with motion,
recurs with rest), weight bearing joints unstable, joint stiffness lasts fewer than 30
minutes. One or more joints can be involved but most common are distal finger joints,
proximal finger joints, first carpometacarpal joint, knees, hips, cervicolumbar spine, and
joint of the great toe. Examination of the joint may reveal tenderness, crepitus, muscle
atrophy, and limited ROM.
Osteoarthritis (OA) treatment goals
Educate the patient and caregivers o Relieve pain o Maintain or restore mobility o
Minimize functional impairment and associated adverse outcomes (like falls) o Preserve
joint integrity o Improve quality of life
Osteoarthritis (OA)
progressive, degenerative joint disease with loss of articular cartilage and hypertrophy
of bone (formation of osteophytes, or bone spurs) at articular surfaces
Provide a stepwise approach to the treatment of osteoarthritis, including non-
pharmacological interventions (figure 58-2).
1) non pharm, 2) pharm (Tylenol APAP/nsaids + glucosamine), then 3) injections,
opioids, surgery *If NSAIDS are contraindicated, then utilize glucocorticoid injections
What is meant by adequate dose / duration and ATC dosing when determining
APAPs effectiveness
APAP: first line therapy for mild to moderate osteoarthritis Apap should be tried
initially at an adequate dose and duration before considering an NSAID* Insufficient
acetaminophen dose or duration are common reasons for inadequte response. APAP
should be given on a PRN basis in divided doses up to 4 g daily. Single doses should
not exceed 1 g. Trial for 4 to 6 weeks. Use 2.5g max for pts who consume 2 to 3
,alcoholic beverages/daily. Consider alternative medications if pain not
managed/presence of severe pain and/or inflammation.
When should NSAIDs be introduced
NSAIDS are a first line therapy for patients with moderate to severe OA or alternative
therapy APAP when APAP fails to provide an acceptable analgesic response or if there
is an inflammatory component. All systemic NSAIDS are associated with adverse GI,
renal, hepatic, cardiovascular, CNS, hypertensive effects.. particularly in older
individuals. Inhibition of the cox-1 enzyme is thought to be responsible primarily for the
adverse effects on the gastric mucosa, kidney, and platelets. Cox-2 inhibitors (Celebrex)
are preferred for patients at high risk for GI complications
Practice question: Understand when you would use Acetaminophen versus an
NSAID or an NSAID instead of Acetaminophen
NSAIDs work best on inflammatory pain or pain mediated by prostaglandins (RA,
menstrual and post-surgical pain) and bony metastasis. NSAIDs come with increased
GIB risk and renal impairment. APAP is a good first line for mild to moderate pain and
considered the first line in low back pain and osteoarthritis. APAP hepatotoxicity has
occurred in those with liver injury or chronic drinkers. (pg 576)*
Who would benefit from COXib?
Coxib or cox 2 inhibitors are preferred for patients at risk for GI complications, especially
when using with a PPI.
OTC products for osteoarthritis
APAP (topical and oral), ibuprofen, naproxen, aspirin), diclofenac gel
- Glucosamine and Chondroitin
which are used to stimulate the cartilage matrix and protect against oxidative chemical
damage. Improves knee symptoms in OA similar to celecoxib. D/C after 3 to 6 months if
no benefit achieved. Do not use glucosamine if allergy to shellfish.
Capsaicin
can also be used to deplete substance P from spinal sensory neurons and decreasing
pain transmission. Not effective for acute pain... because it may take up to 2 weeks of
daily administration to work. Instruct pt to avoid eyes/mucous membranes and wash
hands after application!
, Tramadol
is used for patients unresponsive to other therapies or when other therapies are
contraindicated. Tramadol has been show to relieve OA pain (minimally) and is an
option for pts with contraindications to NSAIDS. - The addition of Tramadol to NSAIDS
or APAP may augment the analgesic effects of a failing regimen and may provide
adequate relief. - Adverse side effects include dizziness, vertigo, nausea, vomiting,
constipation, and lethargy. More pronounced for several days after initiation or dose
increase. Seizures can occur especially when used with tricyclics, and SSRI's. - Should
not be used with MAOI's due to serotonin syndrome.
When are opioids used?
are used for patients unresponsive to other therapies or when other therapies are
contraindicated,
whos pain is severe enough to require opioids.
Opioids adverse effects
sedation, nausea, vomiting, lightheadedness, constipation
Opioid MOA (4 steps)
general: block pain pathways in SC + brain
1: decrease pre-synaptic release of chemical nt's mobilized by pain impulses
2: blockade of post-synaptic effect of these transmitters
3: activation of descending inhibitory pathways to block pain input
4: reduced emotional response to pain by acting on limbic brian area
opioids act on which receptors
stimulate mu, kappa, delta receptors
Risk factors for osteoporosis
age, skinny, smoking, alcoholics, steroids, menopause, malnutrition, family hx,
Asians/whites
What is the recommended amounts of calcium and vitamin D according to NOF
and how can dietary intake be
supplemented
The NOF recommends a daily calcium intake of 1000mg for men ages 51 to 70
- 1200mg for women older than 51 and men older then 71.
AND ANSWERS LATEST UPDATE
BONE AND JOINT DISORDERS
What is the typical presentation of Osteoarthritis and the overall goals of
therapy?
Patients are usually more than 50 years old. May be asymptomatic to severe joint pain
and stiffness. Joint involvement is asymmetric. Inflammation is absent or mild. Cardinal
s/s are use-related joint pain (deep and aching), joint stiffness (abates with motion,
recurs with rest), weight bearing joints unstable, joint stiffness lasts fewer than 30
minutes. One or more joints can be involved but most common are distal finger joints,
proximal finger joints, first carpometacarpal joint, knees, hips, cervicolumbar spine, and
joint of the great toe. Examination of the joint may reveal tenderness, crepitus, muscle
atrophy, and limited ROM.
Osteoarthritis (OA) treatment goals
Educate the patient and caregivers o Relieve pain o Maintain or restore mobility o
Minimize functional impairment and associated adverse outcomes (like falls) o Preserve
joint integrity o Improve quality of life
Osteoarthritis (OA)
progressive, degenerative joint disease with loss of articular cartilage and hypertrophy
of bone (formation of osteophytes, or bone spurs) at articular surfaces
Provide a stepwise approach to the treatment of osteoarthritis, including non-
pharmacological interventions (figure 58-2).
1) non pharm, 2) pharm (Tylenol APAP/nsaids + glucosamine), then 3) injections,
opioids, surgery *If NSAIDS are contraindicated, then utilize glucocorticoid injections
What is meant by adequate dose / duration and ATC dosing when determining
APAPs effectiveness
APAP: first line therapy for mild to moderate osteoarthritis Apap should be tried
initially at an adequate dose and duration before considering an NSAID* Insufficient
acetaminophen dose or duration are common reasons for inadequte response. APAP
should be given on a PRN basis in divided doses up to 4 g daily. Single doses should
not exceed 1 g. Trial for 4 to 6 weeks. Use 2.5g max for pts who consume 2 to 3
,alcoholic beverages/daily. Consider alternative medications if pain not
managed/presence of severe pain and/or inflammation.
When should NSAIDs be introduced
NSAIDS are a first line therapy for patients with moderate to severe OA or alternative
therapy APAP when APAP fails to provide an acceptable analgesic response or if there
is an inflammatory component. All systemic NSAIDS are associated with adverse GI,
renal, hepatic, cardiovascular, CNS, hypertensive effects.. particularly in older
individuals. Inhibition of the cox-1 enzyme is thought to be responsible primarily for the
adverse effects on the gastric mucosa, kidney, and platelets. Cox-2 inhibitors (Celebrex)
are preferred for patients at high risk for GI complications
Practice question: Understand when you would use Acetaminophen versus an
NSAID or an NSAID instead of Acetaminophen
NSAIDs work best on inflammatory pain or pain mediated by prostaglandins (RA,
menstrual and post-surgical pain) and bony metastasis. NSAIDs come with increased
GIB risk and renal impairment. APAP is a good first line for mild to moderate pain and
considered the first line in low back pain and osteoarthritis. APAP hepatotoxicity has
occurred in those with liver injury or chronic drinkers. (pg 576)*
Who would benefit from COXib?
Coxib or cox 2 inhibitors are preferred for patients at risk for GI complications, especially
when using with a PPI.
OTC products for osteoarthritis
APAP (topical and oral), ibuprofen, naproxen, aspirin), diclofenac gel
- Glucosamine and Chondroitin
which are used to stimulate the cartilage matrix and protect against oxidative chemical
damage. Improves knee symptoms in OA similar to celecoxib. D/C after 3 to 6 months if
no benefit achieved. Do not use glucosamine if allergy to shellfish.
Capsaicin
can also be used to deplete substance P from spinal sensory neurons and decreasing
pain transmission. Not effective for acute pain... because it may take up to 2 weeks of
daily administration to work. Instruct pt to avoid eyes/mucous membranes and wash
hands after application!
, Tramadol
is used for patients unresponsive to other therapies or when other therapies are
contraindicated. Tramadol has been show to relieve OA pain (minimally) and is an
option for pts with contraindications to NSAIDS. - The addition of Tramadol to NSAIDS
or APAP may augment the analgesic effects of a failing regimen and may provide
adequate relief. - Adverse side effects include dizziness, vertigo, nausea, vomiting,
constipation, and lethargy. More pronounced for several days after initiation or dose
increase. Seizures can occur especially when used with tricyclics, and SSRI's. - Should
not be used with MAOI's due to serotonin syndrome.
When are opioids used?
are used for patients unresponsive to other therapies or when other therapies are
contraindicated,
whos pain is severe enough to require opioids.
Opioids adverse effects
sedation, nausea, vomiting, lightheadedness, constipation
Opioid MOA (4 steps)
general: block pain pathways in SC + brain
1: decrease pre-synaptic release of chemical nt's mobilized by pain impulses
2: blockade of post-synaptic effect of these transmitters
3: activation of descending inhibitory pathways to block pain input
4: reduced emotional response to pain by acting on limbic brian area
opioids act on which receptors
stimulate mu, kappa, delta receptors
Risk factors for osteoporosis
age, skinny, smoking, alcoholics, steroids, menopause, malnutrition, family hx,
Asians/whites
What is the recommended amounts of calcium and vitamin D according to NOF
and how can dietary intake be
supplemented
The NOF recommends a daily calcium intake of 1000mg for men ages 51 to 70
- 1200mg for women older than 51 and men older then 71.
