The Musculoskeletal System 2 – a Contextualisation

6PY011 The Musculoskeletal System 2 – a Contextualisation Fatimah Abbas Overview – The Study Pack • Therapeutic management of diseases affecting the musculoskeletal (MSK) system: – Diagnosis – Differential diagnoses – Pharmacological and non-pharmacological management • • Advanced drug design and delivery - biologics Relevance to pharmacy practice Learning Outcomes • To understand the relevance to pharmacy practice of: – Minor musculoskeletal ailments – Major illness • • To understand the expanding role of pharmacists in the management of major musculoskeletal illnesses Upon TBL cycle completion – to apply knowledge of the pharmacological and non-pharmacological agents used to manage these conditions Rheumatoid Arthritis (RA) - Diagnosis • Family history – ↑ incidence • Presence of systematic and extra-articular features – e.g. respiratory disease, vasculitis, CVD, Sjögren’s syndrome • Rheumatoid factor – autoantibodies of IgG, IgM and IgA, raised in ~70% patients with RA • Anti-Cyclic Citrullinated Peptide (CCP) antibodies – ↑ sensitivity & specificity to RA, ↑ in RA • Full blood count → neutrophils and WCC - ↑ inflammatory conditions • C-Reactive Protein (CRP) or Erythrocyte Sedimentation Rate (ESR) – may be ↑ in RA • Liver function tests (LFTs) – baseline prior to treatment • Urea & electrolytes (U&Es) – baseline prior to treatment • X-ray of hands and feet – to assess extent of joint degradation Synovitis • Inflammation of the synovium • Joint capsule may also be inflamed • Commonly affects MCP and PIP joints https://www.researchgate.net/publi cation/368585080_Signaling_pathw ays_in_rheumatoid_arthritis_implicat ions_for_targeted_therapy RA - Differentials https://medlineplus.gov/genetics/con dition/systemic-lupus-erythematosus/ RA - Differentials https://creakyjoints.org/living-with-arthritis/symptoms/what-is-tenosynovitis/ RA - Differentials • • • Psoriatic arthritis: – Asymmetric joints affected – Tends to affect lower back, PIP joints – Nail dystrophy and dactylitis common – Often co-exists with psoriasis Reactive arthritis: – Acute onset, usually post-infection – Rheumatoid Factor negative “seronegative” Septic arthritis: – Caused by infection of joint, often bacterial – It left untreated, severe (and permanent) joint damage will occur https:/ /fifevir tualha ndclini c.co.u k/septi carthriti sinfecti on-ofajoint/ RA – Assessing Severity Composite measures of rheumatoid arthritis disease activity: the... | Download Scientific Diagram RA - Management e.g. methotrexate, leflunomide, sulfalsalazine Combined DMARDs* e.g. methotrexate, leflunomide, sulfalsalazine Biologic DMARDs – anti-TNFα & interleukin inhibitors e.g. etanercept, infliximab, adalimumab; tocilizumab Biologic DMARDs - JAK kinase inhibitors e.g. tofacitinib, baricitinib *Titrated to max. tolerated dose NSAID +/Corticosteroid course e.g. PO prednisolone Increasing severity Conventional DMARDs* NSAID +/Corticosteroid course e.g. PO prednisolone RA – Pre-treatment screening RA- Monitoring • • • • • • • • Tuberculosis Hepatitis B & C AIDS & HIV Vaccines; pneumococcal, influenza, chicken pox, shingles • Full blood count Baseline then Liver function tests 3-monthly Urea & electrolytes Inflammatory markers – CRP, ESR, anti-CCP, RF Monitoring for evidence of infection should continue during, and for 6 months after, treatment RA Complications • • • • • Respiratory disease Vasculitis Cardiovascular disease Sjögren’s syndrome Carpal tunnel syndrome Methotrexate • Patients prescribed oral methotrexate should be issued with a “purple” booklet or a booklet to provide – Advice on taking oral methotrexate – Record of blood test results and dosage • • Pharmacists MUST see this booklet when dispensing oral methotrexate to ensure that blood tests are up to date Would you refuse supplying medication to the patient because they have forgotten their booklet? MHRA/CHM advice: Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing (September 2020) Biologics • Multiple drugs AND formulations available on the market • Biosimilars • Increasingly prescribed over past 5 years • Homecare Medicines Service https://www.royalmarsden.nhs.uk/yourcare/pharmacy/homecare-medicines-service Homecare Medicines Services • POM supply of specialist medicines directly to patient’s door 1. 2. 3. 4. 5. • • Patient reviewed in hospital outpatient clinic Blood tests conducted in hospital Medicines prescribed by specialist in hospital Clinical screening by homecare pharmacist Medicine supply by homecare delivery team Multi-disciplinary team (MDT) input NHS and private providers Strontium Ranelate • • • Previous wide use to treat osteoporosis Withdrawn briefly due to cardiovascular ADRs Risks vs. benefits Royal Osteoporosis Society | 2019.01.14 - Strontium ranelate returns to the UK as an osteoporosis drug treatment (theros.org.uk) Musculoskeletal Conditions in the Community Pharmacy A 34-year-old female patient attends your pharmacy reporting lower back pain. Upon further questioning, you determine the following: • • • • • • • • S – lower loins O – no apparent trigger C – spasmic What will you R – pelvic area and why? A – nausea, mild burning pain on urination T – 6 days ago E – paracetamol provides slight and temporary relief only S – 6/10 do Musculoskeletal Conditions in the Community Pharmacy A 34-year-old female patient attends your pharmacy reporting lower back pain. Upon further questioning, you determine the following: • • • • • • • • S – lower loins – ?kidney-related pain or ?UTI O – no apparent trigger C – spasmic – ?renal calculi R – pelvic area – ?UTI ?sciatica ?renal calculi A – nausea, mild burning pain on urination – ?renal calculi ?UTI T – 6 days ago – UTIs may self-resolve within this timeframe E – paracetamol provides slight and temporary relief only suggest moderateS – 6/10 severe pain Key Back pain Soft tissue & muscle injury Both Children <12 and elderly Persistent and/or worsening pain Unexplained bruising/bleeding Major trauma Malaise, fever following and/or rigors accident or injury New back pain in patients aged under 20 years or over 50 years Weight loss No response > 3-4 weeks GP referrals for musculoskeletal pain ? Fracture Myalgia following recent travel or insect bite History of malignancy Associated bladder or bowel symptoms Saddle paraesthesia Inability to weightbear Stiffness Immediate swelling Nausea & vomiting Tingling and radiation down legs Motor weakness in legs or gait disturbance Reading List • • • • • • • • Osteoporosis - Symptoms, diagnosis and treatment | BMJ Best Practice Osteoarthritis in general practice document (versusarthritis.org) Biologics For Rheumatoid Arthritis (RA) | NRAS Professional Standards for Homecare Services (rpharms.com) Medicines Monitoring – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice Prednisolone | Drugs | BNF | NICE → treatment cessation The Glucocorticoid Taper: A Primer for the Clinicians – PMC Steroid tapering guidance | Right Decisions What to Expect in the TBL 1. 2. 3. 4. RATs – individual and team Monoclonal antibodies lecture Clinical cases workshop tAPP exercises Thank you ☺