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550 MuscSkel Exam 1
Kevin's flashcards for Musculoskeletal Exam 1
| Question | Answer |
|---|---|
| Drugs that can induce hyperuricemia | Diuretics Ethambutol Ethanol Nicotinic acid Salicylates (<2g/day) Levodopa Cyclosporin Cytotoxic drugs Pyrazinamide |
| Podagra | Acute mono arthritis of the 1st metatarsal-phalangeal (MTP) joint Up to 90% will experience podagra |
| Pseudogout | Cause by either: Ca2+ pyrophosphate dehydrate Ca2+ hydroxyapatite |
| Tophi | Deposits of monosodium urate crystals Can take ~10 years to develop |
| Gout phamacotherapy | Non-acetylated NSAIDs Corticosteroids Uricosurics Xanthine oxidase inhibitors Febuxostat Allopurinol Colchicine |
| 3 NSAIDs with FDA indication for gout | Indomethacin Naproxen Sulindac |
| Osteophyte | Overgrowth of bone in OA aka bone spurs |
| 3 major components of connective tissue | 1. Ground substance 2. Fibers 3. Cells |
| Types of Connective tissue | 1. Connective tissue proper 2. Cartilage 3. Bone 4. Blood |
| Glycosaminoglycans (GAGs) Types | 1. Chondroitin 2. Heparan 3. Keratin 4. Hyaluronic acid 5. Dermatan |
| Ground substance composition | Water 80% Cell adhesion molecules (CAMs) Proteoglycans |
| Types of CAMs | Fibronectin Laminin Chondronectin |
| Aggrecan | Type of proteoglycan found extensively in articular cartilage high concentration of chondroitin and keratin |
| Types of Fibers | 1. Collagen 2. Elastin |
| Types of Collagen fibers | Type1: found in bone Type 2: found in joint cartilage |
| Cell types | 1. Connective tissue proper: fibroblast 2. Cartilage: Chondroblasts 3. Bone: Osteoblasts, Osteocytes, Osteoclasts |
| Most abundant type of Connective tissue proper | Dense |
| Cartilage types | 1. Hyaline: covers joints 2. Elastic: nose, ear, epiglottis 3. Fibrocartilage: vertebrae |
| Increased cartilage rigidity is due to _______, which contains large amounts of _______ | GAGs (chondroitin, hyaluronic acid), glucosamine |
| TIMP | Tissue inhibitor of matrix metalloproteinase prevents proteases from degrading cartilage |
| PAI | Plasminogin activator inhibitor Prevents activation of plasmin, which activates MMPs |
| Released by chondroblast during anabolism | TIMP PAI CAMs Proteoglycans Collagen fibers |
| Diaphysis | Shaft of long bone location of yellow bone marrow |
| Epiphysis | Head of long bone location of red bone marrow & trabecular (cancellous, spongy) bone |
| Common sites of red bone marrow extraction | head of Humerus and Femur, Sternum, or Hips |
| Haversian system | concentric organization of compact bone Osteon --> Lamellae --> Lacuna --> Haversian canal |
| Lacuna | Area between lamellae where osteoblasts become trapped and turn into osteocytes |
| Canaliculus | Pores that osteocytes connect to each other thru between each lacuna |
| Osteoid | Protein ground substance that fills space in bone tissue |
| Vitamin D3 & PTH can stimulate osteoblasts to secrete _____ | Monocyte colony stimulating factor (M-CSF) |
| M-CSF | Stimulates an osteoclast precursor to bind the RANKL located on osteoblast |
| RANK receptor | located on osteoclast and recognizes RANKL on osteoblast leads to NF-kB production and subsequent synthesis and release of enzymes and acid, causing bone resorption |
| OPG | Osteoprotegrin Binds RANKL to prevent activation of the RANK receptor |
| In chronic Rheumatoid Arthritis (RA), the _____ to ______ ratio is lower than normal | OPG to RANKL |
| Vitamin D synthesis | Sun + Skin + 7-dehydrocholesterol --> Cholecalciferol (Vit D3) |
| Integren | Cell adhesion molecule on osteoclast that binds to vitronectin on the bone |
| Axial Skeleten | 1. Skull 2. Thoracic cage 3. Vertebrae |
| Appendicular Skeleton | 1. Pectoral girdle 2. Pelvic girdle 3. Upper limbs 4. Lower limbs |
| PIP joint | Proximal inter-phalangeal joint primarily affected in RA |
| DIP | Distal inter-phalangeal joint Primarily affected in osteoarthritis |
| 2 types of Synoviocytes | Type A (macrophage like) Type B (fibroblast like) |
| Type A synoviocytes | similar to macrophage (Type A macrophage like cell) acts as immune cell in joint & produces immunomodulators comprises about 1/3 of all synoviocytes |
| Type B synoviocytes | Type b fibroblast like cell synthesizes antibodies (like a plasma cell) |
| PAMPs | Pathogen Associated Molecular Patterns eg Microbes |
| DAMPs | Damage Associated Molecular Pattern eg dead or dying tissue |
| TLR | Toll-like receptor recognizes PAMPs & DAMPs |
| Acute inflammation | characterized by influx of PMN (neutrophils) and exudates lasts minutes, hours, few days triggered by pathogens or injury |
| Major hallmark of chronic inflammation is _______ | Tissue destruction |
| In chronic inflammation __________ play a bigger role than PMNs | Macrophages |
| Hallmark of acute inflammation is __________ | Increased vascular permeability Calor |
| Increased vascular permeability during acute inflammation occurs at _________ | Post-capillary venule |
| Increased vascular permeability during acute inflammation causes plasma oncotic pressure to ______ leading to ________ | Decrease, Edema |
| Extravasation | Movement of Leukocytes from plasma to site of inflammation |
| Steps of Extravasation | 1. Margination 2. Rolling 3. Adhesion 4. Diapedesis |
| Recruitment of leukocytes to site of inflammation occurs primarily at ___________ | Post-capillary venule |
| 4 Families of Adhesion molecules | 1. Selectins 2. Integrins 3. Immunoglobgulin-like 4. Mucin-like |
| ELAM-1 (E-selectin) | Endothelial leukocyte adhesion molecule Found on endothelial cells Activated by TNF, IL-1, LPS, Histamine, Thrombin |
| P-selectin | Found on endothelial cells and platelets Activated by cytokines |
| LAM-1 (L-selectin) | Found on leukocytes and monocytes |
| Important Integrins for inflammation | 1. LFA-1 2. MAC-1 3. VLA-4 all constitutively expressed, activated to high affinity by chemokines Mediate firm adhesion of PMNs to endothelial cells |
| LFA-1 | Lymphocyte function antigen type of integrin |
| MAC-1 | Macrophage adhesion molecule type of integrin |
| VLA-4 | Very late activating antigen type of integrin |
| Ligands for integrins include _______ & ________ | VCAM-1 & ICAM-1 unregulated by cytokines |
| VCAM-1 | Vascular cell adhesion molecule Immunoglobulin-like ligand for integrins |
| ICAM-1 | Intracellular cell adhesion molecule immunoglobulin-like ligand for integrins |
| PECAM-1 | Platelet endothelial cell adhesion molecule immunoglobulin-like involved in diapedesis of leukocytes |
| Chemokines involved in extra vasation | 1. LTB4 2. IL-8 3. C3a & C3b |
| Mechanism of chemotaxis is mediated by activation of ______, which leads to activation of the ____ pathway, and increased cell motility | GPCR PLC |
| Stages of phagocytosis | 1. Recognition 2. Attachment 3. Engulfment |
| C3a is a ______ | chemokine |
| C3b is a _____ | Opsonin |
| _________ causes lysosome rupture | Urate crystals |
| Plasma derived mediators of inflammation | 1. Complement (C3a, C3b, C5a) 2. Bradykinin 3. Thrombin, fibrinopeptides, plasmin |
| Cellular derived mediators of inflammation | 1. Histamine 2. Serotonin 3. Proteases 4. Neuropeptides 5. Prostaglandins 6. Leukotrienes 7. PAF 8. Cytokines 9. Nitric oxide |
| Plasma derived mediators of inflammation are made in the _______ | Liver |
| Histamine is produced in _______, ________, and __________ | Mast cells, basophils, and platelets |
| ________ can produce all the cardinal signs of inflammation | Bradykinin (BK) |
| B2 receptor | BK receptor that causes: vasodilation increased vascular permeability contracts bronchial sm. Muscle hyperalgia mast cell degranulation release of neuropeptides |
| B1 receptor | BK receptor that causes: contraction of bronchial smooth muscle, bone resorption, release of PGs from many cells, & release of cytokines from macrophages |
| Hageman factor | Factor XII leads to formation of thrombin which leads to fibrin production |
| Thrombin and inflammation | engages protease-activated receptors on platelets, endothelial cells, and sm. muscle cells Induces formation of adhesion molecules and cytokines too |
| Kallikrein | Converts complement protein C5 to C5a converts kininogen to bradykinin |
| Plasmin and inflammation | Cleaves C3 to C3a and C3b |
| Factor XIIa initiates these 4 pathways | 1. Coagulation system 2. Kinin system 3. Complement system 4. Plasminogen system |
| Hageman factor is insignificant in ________ inflammation | Chronic |
| Histamine | L-Histidine → Histamine via histidine decarboxylase Released from basophils and mast cells in response to: IgE-antigen complex C3a & C5a Il-1 & IL-8 Neuropeptides Heat, cold, trauma |
| H1 receptor effects | Vasodilation – release of NO and prostacyclin Increase in Vascular Permeability Contraction of Bronchiole Smooth Muscle Contraction of GI tract smooth muscle Stimulation of sensory nerve endings – pain and itching Nausea and vomiting (inner ear, CTZ, |
| H2 receptor effects | Produces positive chronotropic and inotropic effect Powerful stimulant of release of gastric acid and pepsin |
| H3 receptor effects | Presynaptic Inhibits release of neurotransmitters |
| Triple response | Antidromic response redness, wheel, flare Histamine can cause this |
| 5-HT1 receptor | Found on on endothelial cells mediates release of NO & PGs to relax vascular smooth muscle & cause vasodilation also found presynaptically to inhibit the release of NE & decrease vascular tone |
| 5-HT2 receptor | Found on smooth muscle cells mediates contraction of blood vessels, GI tract & bronchial smooth muscle; also found on platelets to cause release reaction & aggregation |
| 5-HT3 receptor | Found on sensory nerve endings mediates itch & pain |
| CGRP | Calcitonin gene-related peptide involved in inflammation and pain response Made in soma and transported to nerve endings |
| Substance P (SP) | Neuropeptide made in soma and transported to nerve endings Acts on NK1 receptor to mediate pro-inflammation and pain |
| __________ depletes nerve endings of substance P | Capsacin |
| Eicosanoids | products derived from metabolism of arachidonic acid |
| Biosynthesis of eicosanoids | PLA2 converts phospholipids into arachidonic acid → which is converted to leukotrienes by lipoxygenases or →converted to Prostaglandins by cyclooxygenases |
| Activators of eicosanoid synthesis | Thermal Chemical Mechanical Bacteria IL-1 SP BK Histamine C3a |
| Substance P is released from Type ___ pain fibers | Type C |
| Substance P is released from ________ & _________ | Type C pain fibers & sensory nerve endings (antidromic) |
| PgE2 mediated effects | Stomach: Increases bicarb, mucous production & decreases acid Kidney: Increase Na+, H2O excretion, GFR, RBF, dilates afferent arteriole |
| PgI2 mediated effects | Stomach: increases mucous, bicarb production, decreases acid Blood vessels: Vasodilation Kidney: Increase Na+, H2O excretion, GFR, RBF, dilates afferent arteriole |
| TxA2 mediated effects | Only in platelets by Thromboxane synthtase Blood vessels: Vasoconstriction |
| IL-10 | Endogenous inflammation inhibitor |
| COX-1 is found only in _________ | Platelets |
| COX-2 can be induced by ____, ____, & _____ | TNF, IL-1, & LPS |
| COX-2 is expressed by ___________ | Inflammatory cells |
| Cytokines involved in RA are; | TNF IL-1 HMGB1 |
| Anti-inflammatory cytokines | IL-4 IL-10 IL-13 |
| Endogenous inhibitors of receptors involved in inflammation | sTNF receptor IL-1 receptor antagonist |
| SOCS | Suppressor of Cytokine Signaling |
| Cysteinyl Leukotrienes | LTC4 ➝ LTD4 ➝ LTE4 Act on CysLT1 receptor |
| Activation of CysLT1 receptor | by Cysteinyl Leukotrienes Smooth Muscle Contraction Eosinophil Migration Edema and Secretions in airway |
| Biosynthesis of Leukotrienes | 1. Phospolipids ➝ Arachadonic acid by PLA2 2. 5-LO is activated by FLAP (5-LO activating protein) 3. Arachadonic acid ➝ Leukotrienes 12-HETE, 16-HETE, & LTA4 by 5-Lipoxygenase (5-LO) |
| Biosynthesis of Cysteinyl Leukotrienes | 1. Occurs like other leukotrienes up to LTA4 2. LTA4 ➝ LTC4 by LTC4 Synthase 3. LTC4 ➝ LTD4 ➝ LTE4 mediated by peptidases |
| LTB4 | Powerful chemotactic agent LTA4 ➝ LTB4 by LTA4 Hydroxylase Increases expression of adhesion molecules Algesic agent – stimulates sensory nerve endings Degranulation of mast cells |
| CysLT1 receptor blocking agents | Singulair (montelukast sodium) Accolate (zafirlukast) |
| 5-LO inhibitor drug | Zyflo (zileuton) |
| PAF | Platelet activating factor Functions: Vasodilation and an inc, vascular permeability ~10,000>histamine Platelet aggregation contraction of bronchial smooth muscle Chemotaxis increases affinity of integrins Releases lysosomal membranes |
| PAF is synthesized in these cells | platelets basophils neutrophils macrophages mast cells endothelial cells |
| 3 Types of Nitric oxide synthase | 1. eNOS (endothelial) 2. nNOS (nerve endings) 3. iNOS (inducible) |
| Direct effect of NO | Vasodilation & relaxation of sm. muscle via cGMP production |
| Concentration of _____ produce the direct (vasodilatory) effect of NO | <1µM |
| iNOS | Inducible and involved in inflammation Produced in macrophages in response to TNF, LPS, interferon, & IL-1 |
| Indirect NO pathway | L-Arginine ➝ L-Citrulline by iNOS which is pro-inflammatory and NO reacts with ROS ➝ ONOO- (peroxynitrate) which is pro-inflammatory |
| 2 important pro-inflammatory functions of NO are ______ & _______ | Induces COX-2 Increases cytokine activity |
| Cytokines released during acute reaction | TNF IL-1 IL-6 IL-8 |
| Biosynthesis of TNF | 1. tmTNF ➝ sTNFα by TACE TACE = TNFα converting enzyme |
| sTNF has greater affinity for the _____ receptor | TNR1 |
| TNFR1 is _________ expressed | Constitutively |
| TNFR2 is __________ | Inducible |
| Lymphotoxin | TNFβ Released from T cells and NK cells |
| TNF mediated responses | 1. Pro-inflammatory cytokine release 2. Hepcidin induction 3. PgE2 production 4. Osteoclast activation 5. Chondrocyte activation 6. Angiogenesis 7. Leukocyte accumulation 8. Endothelial cell activation 9. Chemokine release |
| IL6 plays a prominent role in release of ___________________ | acute phase proteins |
| Caspace | (ICE) IL-1 converting enzyme |
| 2 forms of IL-1 | IL-1α & IL-1β |
| IL-1α | Bound to cell surface function unknown |
| IL-1β | Secreted biologically active form Binds to Type I IL-1 receptor which leads to NFkB production |
| IL-1β can be prompted to release by activation of ______ | TLR |
| Endogenous effects of IL-6 | 1. Differentiate T cells into cytotoxic 2. Thrombocytosis 3. ↑ synovial fibroblasts 4. ↑ VEGF production 5. ↑ release of acute phase proteins 6. ↑ induction of adhesion molecules |
| HMGB1 | High mobility group box 1 Nuclear transcription factor binds to TLR4 to cause both acute and chronic inflammation |
| Omega 3 fatty acids role in anti-inflammation | EPA and DHA can be converted to E and D series resolving (respectively) in the exudate |
| Anti-inflammatory homeostasis | 1. Inflammation is initiated 2. Platelets attach to PMNs 3. Lipid mediator class switching molecules are produced 4. AIF and SPM are produced (pro resolving mediators) 5. Production of Lipoxins (LXA4) Resolvins (RvE1 and RvD1) |
| α7-nicotinic receptors | AcH receptors located in cytokine producing cells stimulation ceases production of NFkB which reduces production of TNF, IL-1, IL-6, IL-8, and HMGB1 and produces analgesic effects |
| Paresthesia | Numbness, tingling |
| Allodynia | Painful response to normally non-noxious stimuli |
| Hyperalgia | Exaggerated painful response to normal noxious stimuli |
| Neuropathic pain displays a _____ response to opiod Tx | Poor |
| Dysesthesia | Abnormal or altered sensation |
| Tic Douloureux | Trigeminal neuralgia Neuropathic damage of CN V |
| Type I Hypersensitivity | IgE mediated (allergies) |
| Cytokines involved in OA | IL-1 IL-6 TNF IL-17 |
| IL-17 leads to production of _____, _____, & ________ | TNF IL-1 IL-6 |
| OA has only 1 real cure... | Joint replacement surgery |
| Type II Hypersensitivity | Antibody mediated (IgG, IgM) against tissue (auto-immune response) |
| Type III Hypersensitivity | Immune Complex mediated soluble antigen deposits on tissue and immune response is elicited |
| Type IV Hypersensitivity | T cell mediated CD4 or CD8 allergic dermatitis |
| 3 signals required for T cell activation | 1. Antigen-MHC interaction 2. Co-stimulators and adhesion molecules 3. Release and stimulation of IL-2 and its receptors |
| MHC | Major histocompatibility complex located on antigen presenting cells (APC) |
| Classes of MHC | 1. Class I binds to CD8 2. Class II binds to CD4 |
| TCR | T cell receptor binds antigen that is presented on MHC molecule |
| CD3 | Co-receptor on CD4 T cells |
| B7 | Co-stimulator molecule located on APCs binds to CD28 on CD8 T cells |
| CD28 | Constitutively expressed co-receptor located on CD8 will only bind APC once B7 has been upregulated |
| IL-2 effects on T cells | 1. Survival 2. Proliferation 3. Differentiation |
| CTLA4 | Cytotoxic T lymphocyte associated antigen Binds B7 with greater affinity than CD28 to prevent T cell activation Orencia is similar to CTLA4 |
| CD40L | CD40 ligand Rapidly expressed on T cells after activation enhances B7 expression on APCs thus increasing T cell activation |
| LFA-1 | Adhesion molecule (integrin) located on T cells activated to high affinity state by IL-2 Ultimately binds ICAM-1 on APC |
| IL-2 receptor | Constitutively expresses β and |
| CD20 | found on B cells |
| First antibody produced | IgM |
| Second antibody produced | IgG |
| Steps of type I reaction | 1. APC activates T cell 2. T cell releases IL-4 & IL-13 onto B cell 3. Causes isotope switching --> IgE 4. IgE --> by mast cells --> degranulate (acute phase) 5. IL-5 is released --> eosinophils 6. Eosinophils release CBP and leukotrienes (late phase |
| Diseases of Type I reactions | Bronchial asthma Allergic rhinitis Sinusitis Food allergies Systemic anaphylaxis |
| Steps of type II reaction | 1. B cells produce antibodies to self tissue (IgG) 2. Abs bind tissue 3. Complement protein C1 binds Fc region of IgG 4. Complement cascade is activated 5. Opsonization or MAC occurs to destroy tissue |
| Diseases of Type II reaction | Autoimmune hemolytic anemia Autoimmune Thrombocytopenia purpura Goodpasture's syndrome Acute rheumatic fever Hashimoto's Myasthenia gravis Graves disease Pernicious anemia |
| Diseases associated with Type III reaction | SLE RA Post- strep glomerulonephritis |
| Steps of Type IV reaction | 1. APC activates CD4 T cell 2. CD4 releases TNF, IL-8, and other cytokines 3.a Macrophages are recruited which engulf antigen 3.b Or, CD8 cytotoxic t cell is recruited which releases enzymes which degrade tissue around |
| Rheumatoid arthritis can be a Type ___, ____, or ____ reaction | 2, 3, or 4 |
| Diseases associated with type IV reaction | Type I diabetes Rheumatoid arthritis Inflammatory bowel disease |
| Nociceptive pain | Normal response via sensory nerves in periphery from tissue damage |
| Neuropathic pain | Damage to or dysfunction of nerves in periphery or CNS |
| 4 mechanisms of inhibiting nociceptive pain | 1. Block primary sensory afferent 2. Block relayed sensory info 3. Interfere with perceptual response 4. Modulate pain response |
| Nociceptors | Free nerve endings Large receptive fields Tonic High depolarization thresholds |
| Pain impulse travels from _______ to the ________, where it ______ _____ and ascends to the ______ and then to the brain | the periphery dorsal horn of spinal cord crosses over thalamus |
| Nociceptors can be either ______ or ________ | GPCRs or ion channels |
| Type c fibers are ________ and secrete ________ _ | unmylenated , Substance P |
| Type Aδ fibers are _________ and secrete _______ | mylenated, glutamate |
| BK & Pgs ________ the threshold for GPCR nociceptor depolarization | Lower |
| Laminae _, _, and _ in dorsal horn are important in pain transmission | 1, 2, and 5 |
| Anteriolateral spinothalamic tract contains both _______ and ______ fibers | slow and fast |
| Neospinalthalamic tract contains _______ fibers | Fast fibers |
| Paleospinothalamic tract contains _______ | Slow fibers |
| N type Ca2+ channel is located _________ on primary pain fibers | Pre synaptically |
| Lyrica, Prialt, and morphine target ________ | presynaptic N type Ca2+ channels on primary pain fibers |
| NE, 5-HT, substance P, and enkephalins can ______ | Modulate pain response |
| Nerves from RVM are _______ | serotonergic |
| Nerves from the locus coeruleus are ______ | noradranergic |
| Major components of endogenous analgesic system | 1. Hypothalamus 2. PAG 3. Raphe nucleus 4. Locus coeruleus 5. Dorsal horn of spinal cord |
| In analgesia, NE acts _______ at the ______ receptors | Presynaptically, α2 |
| In analgesia 5-HT acts ________(place) to _______(action) the membrane | postsynaptically, hyperpolarize |
| In neuropathic pain, Na+ channels are ________, leading to _______ | upregulated, hypersensitivity |
| Tegretol mechanism, indication | Block Na+ channels in neuropathic pain |
| OA is a disease of __________, but also affects the _______, _______, ________, & ________ | Cartilage underlying bone entire joint ligaments & muscles |
| OA is the #__ cause of limited morbidity in U.S. | Number 1 |
| Younger patients tend to develop OA in the ________ | hands |
| ________ & __________ are typically first affected joints | knee and hip |
| OA symptoms | Gradual pain that worsens upon use Stiffness that lessens with use Limited ROM, instability, buckling |
| Primary Osteoarthritis is _________ in origin | Ideopathic |
| Localized OA involves | < 3 joints affected |
| Generalized OA invovles | > 3 affected joints |
| Secondary OA is associated with a __________ | known cause |
| End result of OA pathology | 1. Osteophytes 2. Micro-fractures 3. Decreased weight bearing ability |
| Synovial fluid in OA joint has | 1. High viscosity 2. Leukocytosis (<2000WBC) 3. Yellow to clear color 4. PMNs < 25% 5. No bacteria |
| Crepitus | Bone crackling/creaking sound in OA from bone on bone contact |
| OA on the radiograph | 1. Joint space narrowing 2. Presence of osteophytes 3. Abnormal alignment of joints 4. Inflamed synovium |
| In newly diagnosed RA, serum chemistry will reveal ______ | Elevated ESR |
| In newly diagnosed OA, serum chemistry will reveal | Normal serum chemistry |
| Clinical presentation of OA of hip | 1. Pain in groin, butt, inner thigh 2. Referred pain in knee, thigh 3. Limp 4. Instability |
| Clinical presentation of OA of hand | 1. Unilateral swelling and pain 2. Osteophytes in tip or DIP, PIP 3. Difficulty with fine motor tasks |
| T or F: Gout is an arthritic condition | True |
| Ratio of gout prevalence by sex | Male to female ~8:1 |
| Increased incidence of gout occurs with _______, _________, & _________ | Increasing age, Declining renal function, HTN |
| Uric acid pool in males | 1200mg |
| Uric acid pool in females | 600mg |
| Goal serum uric acid level | < 6mg/dL |
| Risk factors for gout | 1. Age 2. Male gender 3. HTN 4. Impaired renal function 5. Fat 6. Alcohol |
| Meds that can exacerbate gout | 1. Diuretics 2. Nicotinic acid 3. Salicylates >2g/day 4. Ethanol 5. Levadopa 6. Cyclosporin 7. Pyrazinamide |
| ___ of uric acid is excreted in urine | 2/3 |
| ___ of uric acid is excreted in GI tract | 1/3 |
| Dietary precipitating factors of gout | 1. Smoking 2. Ethanol 3. Smoked meats 4. Shell fish |
| Classic acute gout presentation | 1. Intense pain 2. Erythema 3. Warmth 4. Swelling 5. Inflammation |
| Joint that is usually first affected by gout | First metatarsal joint |
| Gout signs | 1. Urate >7g/dL 2. Fever 3. Leukocytosis (>50,000WBC) |
| Gout Dx criteria | 1. > 1 acute attack 2. Rapid inflammation 3. Tarsal or metatarsal attack 4. Hyperuricemia 5. Asymmetric swelling on Xray 6. Cysts on Xray 7. Urate crystals |
| Most common complication with repeated gout attacks | Uric acid nephrolithiasis Occurs in ~10-25% of gout |
| Risk factors for nephrolithiasis | 1. Repeated gout attack 2. Concentrated urine 3. Urine pH <6.0 4. Higher than normal urine uric acid |
| Uricase | Degrades uric acid to allantoin Humans lack this enzyme |
| PRPP synthetase | Converts Ribose-5-P + ATP to PRPP (phosphoribosyl pyrophosphate) |
| PRPP aminotransferase | Converts PRPP + Glutamine → PR-1-amine |
| PR-1-amine | Precursor for (IMP) |
| IMP | Inosine-5'-monophosphate (inosinic acid) |
| IMP dehydrogenase | Converts IMP →GMP |
| GMP | Guananine-5'-monophosphate (guanylic acid) |
| Lyase synthase | Converts IMP → AMP |
| AMP | adenosine-5'-monophosphate (adenylic acid) |
| Purine metabolism | PRPP → PR-1-amine →IMP → Inosine → Hypoxanthine → Xanthine → Uric acid |
| Anaplerotic purine pathways Adenylic acid | PRPP → PR-1-amine → IMP → AMP → Adenosine → Inosine → Hypoxanthine → Xanthine → Uric acid |
| Anaplerotic purine pathway Guanylic acid | PRPP → PR-1-amine → IMP → GMP → Guanosine → Guanine → Xanthine → Uric acid |
| HGPRT | Converts Guanine + PRPP → GMP and/or Converts Hypoxanthine + PRPP → IMP Deficiency in this enzyme can lead to hyperuricemia |
| APRT | Converts Adenine + PRPP → AMP Deficiency in this enzyme can lead to hyperuricemia |
| Xanthine oxidase | Converts Hypoxanthine → Xanthine and Xanthine → Uric acid |
| ____% of urate is secreted in PCT | 50% |
| ~____% of urate is reabsorbed | 45% |
| ~__% of urate is excreted | 10% |
| Phases of acute gout attack | 1. Direct (cellular) phase 2. Indirect (humoral) phase |
| Cellular phase of gout | Involves neutrophil engulfment of urate, release of IL-1, IL-6, IL-1β, neutrophil migration and lysing |
| Humoral phase of gout | Involves urate activating complement |
| Drugs for acute gout attack | 1. NSAIDs a. Colchicine b. COX blockers 2. Steroids |
| Drugs for prophylactic gout Tx | 1. Uricosuric agents 2. Xanthine oxidase inhibitors |
| 4 important cytokines in pathogenesis of OA are ____, ____, _____ and _____ | TNF IL-1 IL-6 IL-17 |
| TNF & IL-1β mediated events in OA | 1. Promotes IL-6 release 2. Promotes MMP release 3. Upregulates iNOS, PLA2, and COX-2 |
| IL-17 mediated events in OA | From T cells Induces formation of IL-1, IL-6, and TNF |
| Basic pathogenesis of OA | 1. Choncrocyte releases IL-1 2. Autocrine that promotes release of MMP and aggrecanases 3. Cartilage breakdown products activate Type A & B synoviocytes 4. Production of Pg, Substance P, cytokines, and proteases 5. Inflammation ensues |
| Cartilage fragments can also elicit a type ______ or ______ immune response | 2 or 4 |
| Pharmacologic activity of APAP | 1. Analgesic 2. Antipyretic |
| Name the bone in purple | Sphenoid |
| Name the bone in green | Ethmoid |
| Name the bone in purple | Ileum |
| Name the bone in yellow | Ischium |
| Name the bone in green | Sacrum |
| Name the bone in red | Pubis |
| APAP is a ________ soluble drug, and is therefore COX selective in the _____ | Lipid, CNS |
| APAP is a weak COX inhibitor in presence of ______ | ROS and peroxides |
| APAP has no effects on _____, ______, or _______ | GI, platelets, or renal function |
| APAP metabolism | 65% conjugation 30% sulfation 5% CYP450 CYP produces toxic NAPQI (the metabolite) GSH reduces metabolite to unreactive metabolite |
| ________ or __________ can be given to replenish the -SH group in APAP toxicity | Mucomist or Captopril |
| SMARDs | Symptom Modifying Anti Rheumatic Drugs 1. NSAIDs 2. DMARDs 3. Steroids |
| DCART | Disease Controlling Anti Rheumatic Therapy No drugs currently in this class |
| ASA is anti-inflammatory at doses of about _________ | 325mg qid |
| Low dose ASA (81mg/day) inhibits _______ | COX-1 |
| COX-2 Preferential | Inhibits COX-2 at low dose, but COX 1 & 2 at higher doses |
| COX-2 Selective | Inhibits COX-2 at maximum dose |
| Low COX 1 to 2 ratio means the drug is more _____ | COX-1 selective |
| High COX 1 to 2 ratio means drug is more ______ | COX-2 selective |
| IC50 | Concentration of drug at which 50% of enzyme is inhibited Lower the number, more potent the drug |
| Pharmacologic Properties of NSAIDs | 1. Anti-inflammatory 2. Anti-pyretic 3. Analgesic 4. Anti-platelet 5. Uricosuric |
| Most NSAIDs are weak _____, and ________ at physiological pH (7.4) | Acids, Ionized |
| Inflamed sites have a(n) ________ environment, therefore NSAIDs are ________ here | Acidic, Unionized |
| The intracellular pH is about ______, therefore NSAIDs are ________ here | 6.8, Ionized and trapped |
| First Rx NSAID marketed was ________ | Indomethacin |
| NSAIDs have anti-inflammatory effects beyond ________ | Pg inhibition |
| Sodium salicylate has no COX-1 activity, but does inhibit inflammation by… | inhibition of PMNs |
| NSAIDs are anti-pyretic by... | Inhibit production of PgE2 which normally causes fever in hypothalamus |
| ASA can also trigger ______ | Lipoxins |
| Low dose ASA inhibits _______ in PCT | Urate Secretion |
| High dose ASA (4g/day) inhibits _______, and is ________ | Everything, Uricosuric |
| Inhibition of COX 1 & 2 can interfere with _________ | Renal function |
| ASA + viral infection in children | Can result in Reye's syndrome |
| Random facts: Dolobid (diflunisal) | Weak inhibitor of COX poor CNS penetraiton |
| Random facts: Indocin (indomethacin) | Potent COX inhibitor causes frontal HA used in PDA |
| Random facts: Clinoril (sulindac) | Prodrug less GI toxicity |
| Random facts: Lodine (etodolac) | More COX-2 selective than other NSAIDs |
| Random facts: Toradol (ketorolac) | Potent analgesic limited anti-inflammatory effects |
| Random facts: Meclomen (meclophenamate) | Mainly used in dysmenorrhea |
| Random facts: Relagen (nabumetone) | Prodrug non-selective |
| Protein binding interactions with NSAIDs | 1. Warfarin 2. Hypoglycemic agents 3. Anticonvulsants |
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