NR565: WEEK 4: MUSCULOSKELETAL & JOINT DISORDERS: TEST
QUESTIONS WITH COMPLETE SOLUTIONS
1) Which of the following statements is recommended for the patient who is
beginning therapy with oral methotrexate for RA?
- Take this medication every day.
- Take iron supplements while taking this drug.
- Avoid drinking grapefruit juice while taking this drug.
- Routine tests of kidney and liver function will be needed. -- Answer ✔✔
Routine tests of kidney and liver function will be needed.
Rationale: Periodic tests of renal and liver function are mandatory for patients
taking methotrexate. Patients taking methotrexate should take folic acid
supplements, not iron supplements. Methotrexate is not a drug that interacts
with grapefruit juice. Methotrexate is taken once weekly.
2) Chelo was just prescribed hydroxychloroquine for rheumatoid arthritis. Which of
the following diagnostic tests should be ordered as a baseline for status
monitoring?
- ophthalmological examination
- hypersensitivity testing
- electrocardiogram
- pulmonary function tests -- Answer ✔✔ opthalmologicial examination
, Rationale: Hydroxychloroquine may cause retinal damage; therefore, so an
ophthalmological examination is necessary at the onset of treatment and every 6
months during treatment. This diagnostic test should be ordered for Chelo to
serve as a baseline for monitoring purposes. Monitoring for lung function and
electrocardiogram changes is not necessary; therefore, these diagnostic tests are
not necessary. Although Chelo and the NP will monitor for evidence of
hypersensitivity, it is not necessary to do testing before beginning therapy with
hydroxychloroquine.
3) Andre was newly diagnosed with rheumatoid arthritis and methotrexate was
prescribed. What is the strongest rationale for prescribing methotrexate?
- Methotrexate can prevent cancer in addition to managing arthritis.
- Starting methotrexate early can help delay joint degeneration.
- Methotrexate is the only drug known to cure rheumatoid arthritis.
- A methotrexate regimen can reduce overall costs. -- Answer ✔✔ Starting
methotrexate early can help delay joint degeneration.
Rationale: Current guidelines for the treatment of RA recommend starting a
disease-modifying antirheumatic drug (DMARD) early—within 3 months of
diagnosis—to delay joint degeneration. Starting methotrexate early can help delay
joint degeneration is the strongest rationale for prescribing methotrexate for
Andre. Methotrexate is expensive and has toxic side effects. This is not the
strongest rationale for prescribing methotrexate for Andre. Although
methotrexate is also used to treat cancer, it does not have a role in cancer
prevention. Therefore, this is not the strongest rationale for prescribing
methotrexate. There is currently no cure for rheumatoid arthritis; therefore, this
is not the strongest rationale for prescribing methotrexate for Andre.
4) Haley is a child with juvenile idiopathic arthritis whose symptoms are inadequately
controlled with methotrexate. The NP is considering prescribing a course of
abatacept for Haley. What information is critical to include when teaching Haley's
family about abatacept?
- A tumor necrosis factor (TNF) antagonist may need to be added if this
therapy is not effective.
- Your child should receive regularly scheduled vaccinations during therapy
with abatacept, but live vaccines should be omitted.
- Abatacept should be given at least 2 hours after methotrexate.
, - Immediately report any symptoms of infection. -- Answer ✔✔ Immediately
report any symptoms of infection.
Rationale: Abatacept suppresses immune function and can increase the risk of
serious infection. Parents should report any evidence of infection, which may
warrant discontinuation of abatacept. This information is critical to include when
teaching Haley's family about abatacept. Abatacept may be taken alone or with
methotrexate; however, they do not need to be separated by 2 hours. Therefore,
this information is not relevant to include. Live vaccines should be avoided;
however, because abatacept can blunt the effectiveness of vaccines, vaccines
should be up to date before therapy or delayed until 3 months after therapy.
Abatacept should not be given with TNF antagonists because of the increased risk
of serious infections.
5) Gayle has RA and takes leflunomide and an oral contraceptive. She reports that
she would like to get pregnant. Which of the following is the best course of
action for Gayle?
- Discontinue both leflunomide and the oral contraceptive and begin folic acid
supplementation.
- Discontinue leflunomide and initiate therapy with methotrexate.
- Taper leflunomide over two weeks before discontinuing the oral
contraceptive.
- Discontinue leflunomide and initiate therapy with methotrexate.
- Discontinue the leflunomide and begin an 11-day course of cholestyramine. --
Answer ✔✔ Discontinue the leflunomide and begin an 11-day course of
cholestyramine.
Rationale: Leflunomide is teratogenic; therefore, it is contraindicated in
pregnancy. Patients desiring pregnancy must follow a three-step protocol that
includes stopping leflunomide, taking cholestyramine to chelate the leflunomide,
and ensuring that leflunomide drug levels are below 20 μg/L before getting
pregnant. This is the best course of action for Gayle. Methotrexate is also
teratogenic and is not safe during pregnancy. This is not the best course of action
for Gayle. Plasma levels of leflunomide may take 2 years to drop without using
cholestyramine. The three-step protocol must be adhered to as the best course
of action.
6) Gout -- Answer ✔✔ -common type of inflammatory arthritis
, - characterized by:
• persistently elevated levels of uric acid in the blood that deposits
within joints & surrounding tissue in the form of crystals
- Untreated gout may cause:
• erosion & irreversible joint damage, renal damage, & tophi.
- can cause frequent urination
7) ACP recommendations to maximize gout outcomes: -- Answer ✔✔ -Choose
corticosteroids, NSAIDs, or colchicine to tx pts with acute gout
- Use low-dose colchicine when using colchicine to tx acute gout
- Avoid initiating long-term, urate-lowering therapy in most patients after a 1st
gout attack or in pts with infrequent attacks
- Discuss benefits, harms, costs, & individual preferences with patients before
initiating urate-lowering therapy
• including concomitant prophylaxis, in patients with recurrent gout
attacks
8) Drug classes used to tx gout -- Answer ✔✔ -NSAIDs
• indomethacin
• naproxen
- Antigout Anti-inflammatory Drug
• short-term
• long-term
• colchicine
- Glucocorticoids
• prednisone
• triamcinolone acetate (IM)
- Xanthine Oxidase Inhibitors
• long-term
• allopurinol
• febuxostat
- Uricosuric Agents
• probenecid
• lesinurad
QUESTIONS WITH COMPLETE SOLUTIONS
1) Which of the following statements is recommended for the patient who is
beginning therapy with oral methotrexate for RA?
- Take this medication every day.
- Take iron supplements while taking this drug.
- Avoid drinking grapefruit juice while taking this drug.
- Routine tests of kidney and liver function will be needed. -- Answer ✔✔
Routine tests of kidney and liver function will be needed.
Rationale: Periodic tests of renal and liver function are mandatory for patients
taking methotrexate. Patients taking methotrexate should take folic acid
supplements, not iron supplements. Methotrexate is not a drug that interacts
with grapefruit juice. Methotrexate is taken once weekly.
2) Chelo was just prescribed hydroxychloroquine for rheumatoid arthritis. Which of
the following diagnostic tests should be ordered as a baseline for status
monitoring?
- ophthalmological examination
- hypersensitivity testing
- electrocardiogram
- pulmonary function tests -- Answer ✔✔ opthalmologicial examination
, Rationale: Hydroxychloroquine may cause retinal damage; therefore, so an
ophthalmological examination is necessary at the onset of treatment and every 6
months during treatment. This diagnostic test should be ordered for Chelo to
serve as a baseline for monitoring purposes. Monitoring for lung function and
electrocardiogram changes is not necessary; therefore, these diagnostic tests are
not necessary. Although Chelo and the NP will monitor for evidence of
hypersensitivity, it is not necessary to do testing before beginning therapy with
hydroxychloroquine.
3) Andre was newly diagnosed with rheumatoid arthritis and methotrexate was
prescribed. What is the strongest rationale for prescribing methotrexate?
- Methotrexate can prevent cancer in addition to managing arthritis.
- Starting methotrexate early can help delay joint degeneration.
- Methotrexate is the only drug known to cure rheumatoid arthritis.
- A methotrexate regimen can reduce overall costs. -- Answer ✔✔ Starting
methotrexate early can help delay joint degeneration.
Rationale: Current guidelines for the treatment of RA recommend starting a
disease-modifying antirheumatic drug (DMARD) early—within 3 months of
diagnosis—to delay joint degeneration. Starting methotrexate early can help delay
joint degeneration is the strongest rationale for prescribing methotrexate for
Andre. Methotrexate is expensive and has toxic side effects. This is not the
strongest rationale for prescribing methotrexate for Andre. Although
methotrexate is also used to treat cancer, it does not have a role in cancer
prevention. Therefore, this is not the strongest rationale for prescribing
methotrexate. There is currently no cure for rheumatoid arthritis; therefore, this
is not the strongest rationale for prescribing methotrexate for Andre.
4) Haley is a child with juvenile idiopathic arthritis whose symptoms are inadequately
controlled with methotrexate. The NP is considering prescribing a course of
abatacept for Haley. What information is critical to include when teaching Haley's
family about abatacept?
- A tumor necrosis factor (TNF) antagonist may need to be added if this
therapy is not effective.
- Your child should receive regularly scheduled vaccinations during therapy
with abatacept, but live vaccines should be omitted.
- Abatacept should be given at least 2 hours after methotrexate.
, - Immediately report any symptoms of infection. -- Answer ✔✔ Immediately
report any symptoms of infection.
Rationale: Abatacept suppresses immune function and can increase the risk of
serious infection. Parents should report any evidence of infection, which may
warrant discontinuation of abatacept. This information is critical to include when
teaching Haley's family about abatacept. Abatacept may be taken alone or with
methotrexate; however, they do not need to be separated by 2 hours. Therefore,
this information is not relevant to include. Live vaccines should be avoided;
however, because abatacept can blunt the effectiveness of vaccines, vaccines
should be up to date before therapy or delayed until 3 months after therapy.
Abatacept should not be given with TNF antagonists because of the increased risk
of serious infections.
5) Gayle has RA and takes leflunomide and an oral contraceptive. She reports that
she would like to get pregnant. Which of the following is the best course of
action for Gayle?
- Discontinue both leflunomide and the oral contraceptive and begin folic acid
supplementation.
- Discontinue leflunomide and initiate therapy with methotrexate.
- Taper leflunomide over two weeks before discontinuing the oral
contraceptive.
- Discontinue leflunomide and initiate therapy with methotrexate.
- Discontinue the leflunomide and begin an 11-day course of cholestyramine. --
Answer ✔✔ Discontinue the leflunomide and begin an 11-day course of
cholestyramine.
Rationale: Leflunomide is teratogenic; therefore, it is contraindicated in
pregnancy. Patients desiring pregnancy must follow a three-step protocol that
includes stopping leflunomide, taking cholestyramine to chelate the leflunomide,
and ensuring that leflunomide drug levels are below 20 μg/L before getting
pregnant. This is the best course of action for Gayle. Methotrexate is also
teratogenic and is not safe during pregnancy. This is not the best course of action
for Gayle. Plasma levels of leflunomide may take 2 years to drop without using
cholestyramine. The three-step protocol must be adhered to as the best course
of action.
6) Gout -- Answer ✔✔ -common type of inflammatory arthritis
, - characterized by:
• persistently elevated levels of uric acid in the blood that deposits
within joints & surrounding tissue in the form of crystals
- Untreated gout may cause:
• erosion & irreversible joint damage, renal damage, & tophi.
- can cause frequent urination
7) ACP recommendations to maximize gout outcomes: -- Answer ✔✔ -Choose
corticosteroids, NSAIDs, or colchicine to tx pts with acute gout
- Use low-dose colchicine when using colchicine to tx acute gout
- Avoid initiating long-term, urate-lowering therapy in most patients after a 1st
gout attack or in pts with infrequent attacks
- Discuss benefits, harms, costs, & individual preferences with patients before
initiating urate-lowering therapy
• including concomitant prophylaxis, in patients with recurrent gout
attacks
8) Drug classes used to tx gout -- Answer ✔✔ -NSAIDs
• indomethacin
• naproxen
- Antigout Anti-inflammatory Drug
• short-term
• long-term
• colchicine
- Glucocorticoids
• prednisone
• triamcinolone acetate (IM)
- Xanthine Oxidase Inhibitors
• long-term
• allopurinol
• febuxostat
- Uricosuric Agents
• probenecid
• lesinurad
