Part 6.3.1 - Drugs for Rheumatologic Disorder - Introduction, Non-Narcotic Analgesics

c. Both

Rheumatologic disorder can be

a. Inflammatory

b. Autoimmune disease

c. Both

d. None

e. None

True about inflammation except:

a. A non-specific immune response against an adverse stimulus

b. Can be caused by microbial invasion

c. Can be caused by physical Injury

d. Main purpose is for body's protection and a part of healing process

e. None

f. None

Cardinal signs of inflammation except:

a. Calor: Heat

b. Rubor: Redness

c. Tumor: Swelling

d. Dolor: Pain

e. Functio laesa: Loss of Function

f. None

e. None

Autoimmune diseases except:

a. Conditions that arise from overreactive immune responses

b. Involved T cells and B cells

c. T cells and B cells → tend to be self-reactive meaning they can adversely target substances & tissues normally present in the body

d. T cells and B cells are designed to address foreign threats but instead they target our own cells leading to abnormality called autoimmune diseases

e. None

f. None

Rheumatologic disorders affect muscoskeletal system including the following except:

a. Joints

b. Muscles

c. Bones

d. Tendons

e. Ligaments

f. None

a. Rheumatoid Arthritis (RA)

Rheumatologic disorder:

Characterized by chronic and systemic inflammation affecting synovium.

a. Rheumatoid Arthritis (RA)

b. Osteoarthritis

c. Systemic Lupus Erythematosus

d. Ankylosing Spondylitis

f. All

Rheumatoid Arthritis (RA)

a. Multiple and symmetrical affecting

b. Morning joint stiffness that last for >30 mins

c. There is hand involvement

d. a and b

e. b and c

f. All

b. Osteoarthritis

Rheumatologic disorder:

Most common joint disease in humans that is not inflammatory, and not autoimmune disease.

a. Rheumatoid Arthritis (RA)

b. Osteoarthritis

c. Systemic Lupus Erythematosus

d. Ankylosing Spondylitis

d. a and b

Osteoarthritis is not inflammatory because it lacks

a. Rubor

b. Calor

c. Pallor

d. a and b

e. b and c

f. All

c. Systemic Lupus Erythematosus

Rheumatologic disorder:

Autoimmune disease that affect women more than men more commonly known as lupus.

a. Rheumatoid Arthritis (RA)

b. Osteoarthritis

c. Systemic Lupus Erythematosus

d. Ankylosing Spondylitis

f. All

malar rash: acute

discoid rash: chronic

Systemic Lupus Erythematosus causes the following.

a. Butterfly-shaped rash or Malar rash in the face

b. Photosensitivity

c. Most common renal complications like nephritis

d. a and b

e. b and c

f. All

d. Ankylosing Spondylitis

Rheumatologic disorder:

Autoimmune disease that usually affects the spinal column of the patient.

a. Rheumatoid Arthritis (RA)

b. Osteoarthritis

c. Systemic Lupus Erythematosus

d. Ankylosing Spondylitis

e. None

Ankylosing Spondylitis except:

a. Affects men more than women

b. Characterized as fusion of the spine or more commonly describe as Bamboo spine

c. Manifested as Enthesitis: Inflammation of the enthesis

d. Manifested as Sacrolitis: Inflammation of sacroiliac joint

e. None

b. Osteoarthritis - not autoimmune, not inflammatory

Autoimmune disease except:

a. Rheumatoid Arthritis (RA)

b. Osteoarthritis

c. Systemic Lupus Erythematosus

d. Ankylosing Spondylitis

e. None

d. Ankylosing Spondylitis

Manifested as enthesitis, and sacrolitis.

a. Rheumatoid Arthritis (RA)

b. Osteoarthritis

c. Systemic Lupus Erythematosus

d. Ankylosing Spondylitis

c. Both

Analgesics

a. Drugs that are used to induce analgesia

b. Can be Non-Narcotics and Narcotic Analgesics

c. Both

d. None

e. a and c

Non-Narcotics

a) Does not cause narcosis

b) p-aminophenol Derivatives (paracetamol)

c) NSAIDs

Non-Narcotics

a. Does not cause narcosis

b. p-nitrophenol Derivatives

c. NSAIDs

d. a and b

e. a and c

f. All

f. All

Acetaminophen or paracetamol

a. Weak prostaglandin inhibitor in periphery; Weak cyclooxygenase inhibitor

b. Has analgesic & antipyretic activity; lacks anti-inflammatory

c. Can cause hepatotoxicity

d. a and b

e. b and c

f. All

f. All

Acetaminophen or paracetamol uses:

a. 1st line agent for osteoarthritis due to relative safety

b. Aspirin substitute for patient with Aspirin effects intolerance

c. They are safe for pregnant women, lactating women and children

d. a and b

e. b and c

f. All

Paracetamol

1st line agent for osteoarthritis.

e. b and c

toxic dose of paracetamol: 4g/day

lethal dose of paracetamol: 15g/day

Risk factor for hepatotoxicity by paracetamol.

a. Higher dose intake than recommended dose; >5mg/kg/day

b. Pre-existing liver disease

c. Concomitant use of CYP1A2 inducers

d. a and b

e. b and c

f. All

e. None

NSAIDs except:

a. Non-steroidal Anti-Inflammatory Drugs

b. Does not possess Cyclopentanoperhydrophenanthrenes (CPPP) nucleus found in steroidal drugs

c. Anti-inflammatory drug due to its mechanism

d. Chemically weak organic acids

e. None

a. Nabumetone

Only NSAID that is not a weak organic acid but instead, a prodrug converted to acetic acid derivative.

a. Nabumetone

b. Ibuprofen

c. Indomethacin

d. Naproxen

e. Aspirin

c. Both

Facilitate conversion of arachidonic acid into prostanoids.

a. Cyclooxygenase (COX)

b. Peroxidase (POX)

c. Both

d. None

a. Cyclooxygenase (COX)

Convert arachidonic acid to PGG2.

a. Cyclooxygenase (COX)

b. Peroxidase (POX)

c. Both

d. None

b. Peroxidase (POX)

Convert PGG2 acid to PGH2.

a. Cyclooxygenase (COX)

b. Peroxidase (POX)

c. Both

d. None

f. All

constitutive enzymes - for housekeeping functions

COX-1

a. Constitutive Enzymes

b. PGs for homeostatic functions

c. Important for gastroprotection and renal vasodilation for enhance renal clearance

d. a and b

e. b and c

f. All

f. All

COX-2

a. Inducible Enzymes

b. Triggered due to certain adverse stimulus like microbial invasion and physical injury

c. Responsible for producing prostaglandins for inflammation which is PGE2

d. a and b

e. b and c

f. All

d. a and b

Selective COX-2 inhibitor NSAIDs are safer for the stomach

Indomethacin, oxicam derivatives: COX-1 »»» COX-2

True statements.

a. Majority of NSAIDs are non-selective COX inhibitors

b. Some NSAIDs block COX-1 more than COX-2

c. Selective COX-1 inhibitor NSAIDs are safer for the stomach

d. a and b

e. b and c

f. All

a. I, II, III, IV, V, VI, VII, VIII

Non-selective COX inhibitor

I. Aspirin

II. Pyrazolones derivatives

III. Indole derivatives

IV. Pyrole alkalonic acid derivatives

V. Phenylacetic acid derivatives

VI. Fenamates

VII. Oxicam derivatives

VIII. Propionic acid derivatives

a. I, II, III, IV, V, VI, VII, VIII

b. I, II, III, IV, V, VI,

c. III, IV, V, VI, VII, VIII

d. I, II, III, IV, V,

e. I, II, VII, VIII

Aspirin

The only irreversible COX inhibitor.

Aspirin

NSAID prototype.

f. None

Aspirin pharmacologic effects except:

a. Analgesic

b. Anti-inflammatory

c. Antipyretic

d. Antiplatelet

e. Anticancer

f. None

f. All

Aspirin at <600mg/day

a. Analgesic

b. Central mechanism: Inhibits pain perception at subcortical sites

c. Peripheral mechanism: Irreversible COX inhibitor

d. a and b

e. b and c

f. All

c. Both

Aspirin at 3.2-4.0 g/day

a. Anti-inflammatory

b. Peripheral mechanism: irreversible COX inhibitor

c. Both

d. None

f. None

Aspirin at 0.3 -1.2 g/day except:

a. Antipyretic

b. Central mechanism: Inhibits response to interleukin-1

c. Block of endogenous pyrogen, IL-1, leading to ↓Body temperature

d. Peripheral mechanism: irreversible COX inhibitor

e. Causes cutaneous vasodilation

f. None

d. a and b

Aspirin at NMT 325 mg/day

a) Antiplatelet

b) TXA2 synthesis inhibition - a potent aggregator

c) Bleeding

Aspirin at NMT 325 mg/day

a. Antiplatelet

b. TXA2 synthesis inhibition

c. Clotting

d. a and b

e. b and c

f. All

a. Chronic inflammation associated to overexpression of COX-2

Aspirin potential use in cancer is attributed to

a. Chronic inflammation associated to overexpression of COX-2

b. Chronic inflammation associated to overexpression of COX-1

c. Acute inflammation associated to overexpression of COX-2

d. Acute inflammation associated to overexpression of COX-1

e. None

c. Both

Gastritis and gastrointestinal ulcer bleeding

- Related to its COX-1 inhibition property resulting to negative alteration of cytoprotection

- treated with Proton pump inhibitors (PPIs): 1st line agents for inhibition of hydrochloric acid

- formerly treated with Misoprostol: alternative but was already banned due to its abortifacient effect

Glomerular Filtration Rate (GFR)

- Alteration in prostaglandins

- Prostaglandin made by COX-1 is important for renal vasodilation which is essential in ↑ GFR

- Aspirin then ↓ Prostaglandin level needed for renal vasodilation resulting to ↓ GFR

Aspirin toxicities

a. Gastritis and gastrointestinal ulcer bleeding

b. Decrease in Glomerular Filtration Rate

c. Both

d. None

b. Uricosurics agonism - should be urucosurics ANTAGONISM.

Aspirin toxicities except:

a. Hypersensitivity Reactions

b. Uricosurics agonism

c. CNS toxicity

d. Reye's Syndrome

e. None

c. Both

Hypersensitivity reactions by Aspirin.

a. NSAID-induced Bronchial Asthma

b. ASA Hypersensitivity Syndrome

c. Both

d. None

a. NSAID-induced Bronchial Asthma

LOX causes bronchospasm = asthma

Hypersensitivity reactions by Aspirin cause by more activation of LOX because of inhibition of COX.

a. NSAID-induced Bronchial Asthma

b. ASA Hypersensitivity Syndrome

c. Both

d. None

b. ASA Hypersensitivity Syndrome

Hypersensitivity reactions by Aspirin manifested as nasal polyposis & chronic sinusitis.

a. NSAID-induced Bronchial Asthma

b. ASA Hypersensitivity Syndrome

c. Both

d. None

f. All

Antagonized uricosuric effect of uricosurics.

a. Aspirin

b. Tolmetin

c. Salicylates

d. a and b

e. b and c

f. All

d. <2 g/day

Aspirin dose that can decrease renal excretion of urate.

a. <5 g/day

b. <4 g/day

c. <3 g/day

d. <2 g/day

a. True

Aspirin is contraindicated to gout patients taking urocosurics.

a. True

b. False

a. Salicylism

headache, tinnitus, vertigo

Mild CNS effects of aspirin.

a. Salicylism

b. Acid-base imbalances, Hallucinations

c. Respiratory depression

f. All

Manifestations of Salicylism.

a. Hyperthermia

b. Tinnitus

c. Hyperventilation

d. a and b

e. b and c

f. All

b. Acid-base imbalances, Hallucinations

Severe CNS effects of aspirin.

a. Salicylism

b. Acid-base imbalances, Hallucinations

c. Respiratory depression

c. Respiratory depression

Fatal CNS effects of aspirin.

a. Salicylism

b. Acid-base imbalances, Hallucinations

c. Respiratory depression

d. Reye's Syndrome

→ would result to hepatic encephalopathy

Observed in children taking aspirin with fever & viral infection.

a. Salicylism

b. Acid-base imbalances, Hallucinations

c. Respiratory depression

d. Reye's Syndrome

c. Both

Fatal complications of Reye's Syndrome by aspirin.

a. Hepatic Failure

b. Encephalopathy

c. Both

d. None

f. All

Pyrazolone derivatives

a. Phenylbutazone

b. Dipyrone

c. Sulfinpyrazone

d. a and b

e. b and c

f. All

c. Sulfinpyrazone

Pyrazolone derivative that is not an NSAID but a uricosuric agent.

a. Phenylbutazone

b. Dipyrone

c. Sulfinpyrazone

d. a and b

e. b and c

f. All

f. All

Pyrazolone derivatives.

a. Analgesic

b. Anti-inflammatory

c. No longer clinically impactful due to certain hematologic and nephro toxicities

d. a and b

e. b and c

f. All

f. All

Pyrazolone derivative hematologic toxicities.

a. Thrombocytopenia (↓ Platelet count)

b. Aplastic Anemia (↓ Platelet count, ↓ RBC, ↓ WBC)

c. Agranulocytosis (↓ Granulocyte count: Basophils, Eosinophils, Neutrophils)

d. a and b

e. b and c

f. All

f. All

Pyrazolone derivative nephrotoxicities.

a. Acute Tubular Necrosis

b. Anasarca

c. Nephrotic Syndrome

d. a and b

e. b and c

f. All

f. None

Indole derivatives except:

a. Indomethacin

b. Blocks COX-1 > COX-2

c. Can cause gastric effects at a higher extent than other NSAIDs

d. a and b

e. b and c

f. None

f. All

Bartter syndrome - disrupts salt and electrolyte imbalance → low K+, metabolic acidosis

Uses of indomethacin

a. To enhance closure of Patent Ductus Arteriosus

b. Management of Bartter Syndrome

c. Treatment of pain in acute gout

d. a and b

e. b and c

f. All

Indomethacin

Used to enhance closure of Patent Ductus Arteriosus.

Indomethacin

Management of Bartter Syndrome

Treatment of pain in acute gout.

b. Tolmetin

Pyrrole alklanoic acid derivative.

a. Indomethacin

b. Tolmetin

c. Sulindac

d. Mefenamic Acid

a. I, II, III, IV, V, VI

Phenylacetic acid derivatives

I. Sulindac

II. Alclofenac

III. Diclofenac

IV. Ketorolac

V. Etodolac

VI. Nabumetone

a. I, II, III, IV, V, VI

b. I, II, III

c. IV, V, VI

d. I, II, III, IV, V

e. II, III, IV, V, VI

b. I, II, III

SAD

Sulindac

Alclofenac

Diclofenac

Phenylacetic acid referred to as the true phenylacetates.

I. Sulindac

II. Alclofenac

III. Diclofenac

IV. Ketorolac

V. Etodolac

VI. Nabumetone

a. I, II, III, IV, V, VI

b. I, II, III

c. IV, V, VI

d. I, II, III, IV, V

e. II, III, IV, V, VI

c. IV, V, VI

KEN

Ketorolac

Etodolac

Nabumetone

Acetic acid derivatives.

I. Sulindac

II. Alclofenac

III. Diclofenac

IV. Ketorolac

V. Etodolac

VI. Nabumetone

a. I, II, III, IV, V, VI

b. I, II, III

c. IV, V, VI

d. I, II, III, IV, V

e. II, III, IV, V, VI

a. Sulindac

Can cause Steven Johnson Syndrome and Toxic Epidermal Necrolysis

a. Sulindac

b. Alclofenac

c. Diclofenac

d. Ketorolac

e. Etodolac

f. Nabumetone

d. Ketorolac

Can be used as treatment for pain after surgery (Especially when anaesthesia effect has worn off).

a. Sulindac

b. Alclofenac

c. Diclofenac

d. Ketorolac

e. Etodolac

f. Nabumetone

f. All

Fenamates.

a. Mefenamic Acid

b. Meclofenamic Acid

c. Flufenamic Acid

d. a and b

e. b and c

f. All

f. all

antipyretic: > 6 months

anti-inflammatory: > 14 yrs

Fenamates.

a. Analgesic

b. Anti-inflammatory

c. Antipyretic

d. a and b

e. b and c

f. All

a. Mefenamic acid - Fenamates should never be given to children.

*based on notes:

anti-pyretic: > 6 months

anti-inflammatory: > 14 yrs

Should never be given to children.

a. Mefenamic acid

b. Ibuprofen

c. Paracetamol

d. Ketorolac

e. Aspirin

b. Ibuprofen

Safest NSAID to children.

a. Mefenamic acid

b. Ibuprofen

c. Paracetamol

d. Ketorolac

e. Aspirin

f. All

Oxicam derivatives

a. Piroxicam

b. Can cause bleeding and ulceration

c. Block COX-1 in greater extent than COX-2

d. a and b

e. b and c

f. All

f. All

Propionic acid derivatives

a. Analgesic

b. Anti-inflammatory

c. Antipyretic

d. a and b

e. b and c

f. All

Naproxen

When patient has fever, patient is not responsive to 1st line antipyretics like Aspirin or Acetaminophen but is sensitive to Naproxen → tumor fever

Used in Fever of Malignancy in which it can be used as a confirmatory agent if patient has cancer.

f. All

Specific COX-2 inhibitors

a. Less associated to gastric effects like gastritis and gastrointestinal ulcer bleeding

b. Increased risk of acute thrombotic events to patient with cardiovascular problems

c. May lead to myocardial infarction and stroke

d. a and b

e. b and c

f. All

e. None

Specific COX-2 inhibitors except:

a. Celecoxib

b. Etoricoxib

c. Valdecoxib

d. Rofecoxib

e. None

f. c and d

Rofecoxib - MI, stroke

Specific COX-2 inhibitors already withdrawn from the market due to toxic effects.

a. Celecoxib

b. Etoricoxib

c. Valdecoxib

d. Rofecoxib

e. a and b

f. c and d

A. Bone marrow toxicity and hepatotoxicity

What are the primary watch-out toxicities for Methotrexate?

A. Bone marrow toxicity and hepatotoxicity

B. Ototoxicity and nephrolithiasis

C. Pulmonary fibrosis and pancreatitis

D. Cardiotoxicity and hypothyroidism

B. Leucovorin (Folinic Acid)

What rescue agent is administered to treat or prevent Methotrexate toxicity?

A. N-acetylcysteine

B. Leucovorin

C. Deferoxamine

D. Naloxone

B. Degenerative wear-and-tear condition

What type of joint condition is Osteoarthritis (OA)?

A. Autoimmune condition

B. Degenerative wear-and-tear condition

C. Infectious condition

D. Metabolic storage condition

B. Malar rash

What is the acute skin manifestation characteristic of Systemic Lupus Erythematosus (SLE)?

A. Discoid rash

B. Malar rash

C. Target lesions

D. Psoriatic plaques

A. Anti-dsDNA

Which specific antibody level is measured to track active disease activity in Systemic Lupus Erythematosus (SLE)?

A. Anti-dsDNA

B. Anti-Ro

C. Anti-Sm

D. Anti-histone

B. It decreases prostacyclin (PGI2) while leaving Thromboxane A2 unopposed

Why does selective COX-2 inhibition increase the risk of myocardial infarction (MI) and stroke?

A. It decreases mucus production in the stomach

B. It decreases prostacyclin while leaving Thromboxane A2 unopposed

C. It direct induces coronary vasospasm

D. It destroys vascular endothelial cells

A. Allergy, nasal polyps, and asthma

What three conditions make up Samter's Triad in Aspirin-Exacerbated Respiratory Disease (AERD)?

A. Allergy, nasal polyps, and asthma

B. Fever, rash, and joint pain

C. Tinnitus, vertigo, and headache

D. Peptic ulcer, hypertension, and renal failure

B. Headache, tinnitus, and vertigo

What classic triad of symptoms indicates mild Aspirin toxicity (Salicylism)?

A. Nausea, vomiting, and diarrhea

B. Headache, tinnitus, and vertigo

C. Fever, rash, and itching

D. Seizures, coma, and arrhythmia

B. Urinary alkalinization using Sodium Bicarbonate

How is severe Aspirin overdose managed using urinary pH manipulation?

A. Urinary acidification using Ammonium Chloride

B. Urinary alkalinization using Sodium Bicarbonate

C. Fluid restriction

D. Administration of loop diuretics

B. Piroxicam

Which NSAID carries the highest risk of causing Peptic Ulcer Disease (PUD)?

A. Ibuprofen

B. Piroxicam

C. Celecoxib

D. Mefenamic acid

A. Sulindac

Which NSAID prodrug is used to prevent familial intestinal polyposis?

A. Sulindac

B. Ketorolac

C. Diclofenac

D. Meloxicam

A. Indomethacin

Which NSAID is indicated to promote closure of Patent Ductus Arteriosus (PDA)?

A. Indomethacin

B. Naproxen

C. Mefenamic acid

D. Celecoxib

A. Naproxen

Which NSAID is uniquely used in the diagnosis of tumor fever?

A. Naproxen

B. Ibuprofen

C. Ketoprofen

D. Etodolac

CPR

Coma

Pinpoint pupils

Respiratory depression

What is the classic Triad of Toxicity for Opioid overdose?

B. Miosis, Convulsions, and Constipation

Which Opioid side effects are considered "constants" because tolerance does NOT develop to them?

A. Euphoria, Analgesia, and Sedation

B. Miosis, Convulsions, and Constipation

C. Respiratory depression and Nausea

D. Hypotension and Bradycardia

B. Truncal rigidity

What unique toxic side effect is specifically associated with high doses of Fentanyl?

A. Nephrolithiasis

B. Truncal rigidity

C. Ototoxicity

D. Aplastic anemia

B. 80 mg/dL and above

At what serum salicylate level does hyperthermia and metabolic acidosis typically occur?

A. 50 mg/dL and above

B. 80 mg/dL and above

C. 110 mg/dL and above

D. 160 mg/dL and above

D. 160 mg/dL and above

At what serum salicylate level does renal and respiratory failure occur?

A. 50 mg/dL and above

B. 80 mg/dL and above

C. 110 mg/dL and above

D. 160 mg/dL and above

A. 50 mg/dL and above

Salicylism: headache, tinnitus, vertigo

At what serum salicylate level does salicylism occur?

A. 50 mg/dL and above

B. 80 mg/dL and above

C. 110 mg/dL and above

D. 160 mg/dL and above

C. Sulfinpyrazone

Which Pyrazolone derivative is utilized specifically as a uricosuric agent?

A. Oxyphenbutazone

B. Phenylbutazone

C. Sulfinpyrazone

D. Tolmetin

B. Ketoprofen

Which NSAID exhibits a dual mechanism of action by inhibiting BOTH COX and LOX enzymes?

A. Ibuprofen

B. Ketoprofen

C. Naproxen

D. Mefenamic acid