Rheumatoid Arthritis (RA) 476; * An antimalarial drug used in rheumatoid arthritis. A) Azathioprine B) Cyclosporine ©) Btanercept D) Infliximab E) Hydroxychloroquine F) Rituximab 477: * A monoclonal antibody that binds to CD20 B lymphocytes. A) Abatacept B) Cyclosporine C) Etanercept D) Infliximab E) Hydroxychloroquine F) Rituximab 478: * A monoclonal antibody that binds to tumor necrosis factor-a. A) Abatacept B) Cyclosporine C) Etanercept D) Infliximab E) Hydroxychloroquine F) Rituximab 479: * This drug that binds to CD28 on the T cell surface. A) Abatacept B) Cyclospori D) Infiximab eee C) Etanercept E) Hydroxychloroquine F) Rituximab 480: ** Which of the followis is i | effects? NE Ar¥Rs is most likely to decrease severity of methotrexate A) Polinic acid B) Vitamin E D) Cholestyramine B) Colchicine ©) Vitamin C1, # 52-year-old woman recently diagnosed with mild rheumatoid arthritis started a therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), but 2 months later, the physician decided to add a discase-modifying antirheumatic drug (DMARD) to the therapeutic regimen. Which of the following is most likely the main advantage of DMARDs over NSAIDs in the treatment of rheumatoid arthritis? ‘To cause fewer adverse effects To slow down the progression of bone and cartilage destruction (To improve symptoms after one week of therapy ) To completely cure the disease, ater 2 to 4 months of therapy £) To completely abolish acute joint pain 2: ** A ST-year-old man recently diagnosed with mild rheumatoid arthritis complained to his physician of joint pain despite ongoing therapy with ibuprofen. The man was a heavy smoker and had a history of chronic bronchitis with frequent acute exacerbations usually treated with antibiotics. The physician decided to add a disease-modifying antirheumatic dmg (DMARD) to the treatment. Which of the following drugs would be most appropriate for the patient at this time? A) Leflunomide B) Hydroxychloroquine ©) Rituxima D)Btanercept B) Azathioprine 483: * A 44-year-old woman suffering from rheumatoid arthritis recently had leflunomide added to her methotrexate therapy. Inhibition of which of the following enzymes most likely mediated the therapeutic effect of the drug in the patient’s disease? A) Cyclooxygenase-1 B) Type II topoisomerase © Dihydrofolate reductase D) Dihydroorotate dehydrogenase 484: *** 4 39-year-old woman complained to her physician of joint pain that had worsened over the past month. The pain was worst in the morning and prevented her from performing her household tasks for at least an hour after waking. She tried ibuprofen three times ‘daily for 2 weeks, but relief was poor, and she stopped the medication because of pigastric pain, The woman was also suffering from chronic active hepatitis B, currently treated with lamivudine. On physical examination, the patient appeared uncomfortable with any movement. Her wrists, metacarpophalangeal joints, and knees showed bilaterally symmetrical swelling, tenderness, and warmth, Further exams confirmed the diagnosis, and a pharmacotherapy was prescribed. Which of the following drugs would be appropriate for the patient at this time? 3 Methotrexate B) Aspirin ©) Btanercept Piperacittin E) Ciprofloxacin F) Erythromycin =Aisorders men 1d man complained to his physician of blurred vision, night bing flashes, and photophobia. The man was diagnosed with mild theumatoig .%> months ago and was taking a combination therapy that included a Aiscase-moggt vinticheumatic drug (DMARD). Ophthalmoscopy disclosed a maculae hyperpigmentation. surrounded by a zone of hypopigmentation on the left retina « amie following drugs most likely caused the patient's signs and symptomyy = VM A) Leflunomide B) Hydroxyehloroquine ©) Rituximab D) Etanercept F) Azathioprine treatment of RA? A) TNF-a inhibitor ©) IL-6 receptor blocker 486: * Which of the following correctly represents the mechanism of action Of Tofacitini in ty B) Inhibitor of Janus kinases D) Dihydrofolate reductase inhibitor 487: ** Which of the following drugs is most likely to increase serum concentrations of conventional doses of methotrexate, a weak acid that is primarily cleared in the rin? A) Acetaminophen _B) Allopurinol C) Colchicine D) Hydroxychloroquine E) Probenecid 488: ** Which of the following agents is prodrug used in rheumatoid arthritis? A) Leflunomide B) Hydroxychloroquine ©) Rituximab D) Etanercept E) Azathioprine 9: ** Leflunomide should be discontinued in women to become pregnant for at least 2 yes or if plasma levels of A771726 less than 0,02 mg/L. Which of the following agents wed to washout Leflunomide metabolites? A) Folinie acid B) Vitamin E ©) Vitamin C D) Cholestyramine E) Colchicine ; 490; ** Which ofthe following agents uses as long as with Infliximab to decrease or preve! ™ formation of anti-infliximab antibodies? A) Cholestyramine —_B) Colchici ‘tux D) Methotrexate ) Etanereept ee 491: ** Which of the following biolo, in sic agents can line monothers) rheumatoid arthritis? be used as first-line A) Tocilizumab By : D) Anakinra } Etanercept ©) Rituximabrich part of a joint does osteoarthritis usually first affect? whi sw B) Cartilage wo 7 p re ifthe above «which of these makes it more likely to get osteoarthritis? ©) Tendon | Be yank age B) Excess body weight , ight D) Back pain tle body weigl p Sieber the above ‘ot * How can an X-ray help a doctor diagnose osteoarthritis? tcan show cartilage loss B) It can show bone damage a can show bone spurs D) All of the above _g5:* Which of these medicines is used to treat osteoarthritis? A) Aspirin B) Acetaminophen () Cotticosteroid injections D) All of the above {96:* Which of these can help prevent osteoarthritis? A) Maintain a healthy weight B) Use good posture C) Start new activities slowly D) All of the above Osteoporosis {91:* Osteoporosis is a disorder of: A) Decreased bone mass. B) Autoimmune disorder _ OIncreased estrogen level D) All of the above | 6%: * Which fa sotuble vitamin is essential to Preventing osteoporosis? A) Vitamin A, B) Vitamin E © Vitamin K D) Vitamin D ‘65:* Which of the following drugs is routinely added to calcium supplements and milk for the Purpose of preventing rickets in children and osteomalacia in adults? Ay Cholecateiferol B) Calcitriol C) Gallium nitrate ) Sevelamer E) Plicamycin, "How does estrogen affect bone’? *) Balances resoy ti 8) Contotstevetg of vit ‘Ontrol levels of | Onto levels of and formation itamin D and calcium metabolism Parathyroid hormone calcitonin hormone eeBone and Joint Disorders a 501: * What is the active form of Vitamin D? @ A) 25-hydroxyvitamin D B) 20-hydroxyvitamin D C) 1,20-dihydroxyvitamin D D) Calcitriol 502: * In normal bone metabolism, what happens when blood Ca” levels ae highp A) Calcitonin release B) Parathyroid hormone release ©) Vitamin D activation D) Increase Ca reabsorption 503: * In normal bone metabolism, what happens when blood Ca’* levels are low? A) Calcitonin release B) Parathyroid hormone release ©) Vitamin D activation D) Increase Ca reabsorption 504: * Which tool is known as the ‘Gold Standard’ for diagnosing osteoporosis? A) Biochemical markers of bone B) X-ray ) Ultrasound of heal D) DEXA Dual energy x-ray absorptionety 505: * Alendronate is used in treatment of osteoporosis because it: A) Inhibits osteoclastic activity B) Inhibits osteoblastic activity C) Increases calcium absorption D) Activates PTH 506: * Which of the following serious side effects of oral bisphosphonates? A) Calcium deficiency B) Leukopenia ©) Esophageal ulcers D) Fever ‘507: * Which of the following is not an antiresorptive drug? A) HRT B) Alendronate ©) Calcitonin D) PTH 508: * What is the most frequent secondary cause of osteoporosis in adults? A) Hypergonadism B) Hypogonadism C) Hypothyroidism D) Hypoparathyroidism ‘509: * In addition to glucocorticoids, what other drug can put a person for risk of developig ‘osteoporosis? A) Anticonvulsants B) Chronic heparin therapy C) Antipsychotic drugs D) SSRIs E) Proton pump inhibitors F) Thyroxine G) Alcohol H) Cyclosporin 1) All of the above J) None of the above } 510 * Which of the following is correct regarding the pharmacokinetics of the bisphosphonate? | A) Bisphosphonates are well absorbed after oral administration. 1B) Food or other medications greatly impair absorption of bisphosphonates C) Bisphosphonates are mainly metabolized via the cytochrome P450 system. D) Elimination half-life of bisphosphonates ranges from 4 to 6 hours. 130, peProp is 65-year-old female who has been diagnosed with postmenopausal I ghe has no history of fractures and no other pertinent medical conditions. Which of the following would be most appropriate for management of her osteopor dronate B) Calcitonin aur D) Raloxifene eripratide TT is 55-year-old female who has been diagnosed with postmenopausal osteoporosis. She has a past medical history of ethanol abuse, alcoholic liver disease, erosive esophagitis, and hypothyroidism. Which of the following would be the primary reason coral bisphosphonates should be used with caution in this patient? ayase B) Erosive esophagitis pLiver disease D) Thyroid disease a3: VS. is a 70-year-old female who is being started on Ibandronate once monthly for the treatment of osteoporosis, Which of the following is important to communicate to this patient? |) Take this medication with orange juice to increase absorption 3) Take this medication after meals to minimize stomach upset QReimain upright for at least 60 minutes after taking this medication D) Adverse effets may include blood clots and leg cramps 414: A 59-year-old female was referred to your clinic for evaluation of osteopenia, She was diagnosed with adult-onset cystic fibrosis (CF). She reported being treated with prednisone 2 times in the past for CF exacerbations. Since menopause at 52 years of age, she had been treated with raloxifene for osteoporosis prevention. She also was on daily calcium and vitamin D supplementation. Her bone mineral density test revealed aT score of-1.6 at the lumbar spine, ~2.2 at the left femoral neck, and -1.6 at the total left hip. Which of the following drugs can be used to reduce the fracture risk by further stimulating bone formation in this patient? A) Cholecaleiferol B) Ergocaleiferol ©) Furosemide D) Tamoxifen E) Teriparatide 515:** If osteoporosis patient's condition was not sufficiently controlled with alendronate, so she began therapy with a nasal spray containing a protein that inhibits bone resorption. ‘The drug contained in the nasal spray was which of the following? 1Caleitonin B) Caleitriol ©) Cinacaleet ) Cortisol E) TeriparatidePa rar rae Bone and Joint Disorders Pie anser i ae ee ARS Tateeena a first Selective Uric «uid Reabsorption Inhibitor (SURD, it was FDA approved on De a peraaenaea on December, spsThe answer is B (Pharma Guide On He gningate With recombinant urate oxida or resistant chronic gout. Page; 479): Peploticase is a polyethylene glycol Se enzyme used in treatment It of severe, refractory be is DP, Page; 479): Lesinurad used only in combination the treatment of hyperuricemia associated Pat en 'arget serum uric acid levels with a xanthine oxidase inhibitor alone [NOT USED ALONE], and contraindicated in severe renal impairment and tumor lysis syndrome 4g: The answer is C (Pharma Guide + page: 479): Rasburi axidase enzyme used in prevention and treatment of hyperu Lysis Syndrome (TLS). se is a recombinant urate ricemia caused by Tumor 476; The answer is E (Pharma Guide °"t! page. 487): Hydroxychloroquine is an antimalarial drug, the ant-inflammatory action in rheumatic diseases is unclear. ai The answer is F (Pharma Guide «+ page; 491): Rituximab is a genetically engineered chimeric (murine/human) monoclonal antibody directed against the CD20 antigen found on the surface of normal and malignant B lymphocytes, resulting in B-cell depletion. 478:The answer is D (Pharma Guide °"*'"*! page; 490): Etanercept and Infliximab are anti- TNF agents, Etanercept consisting of two soluble fully human TNF p75 receptor moieties, while Infliximab bind with soluble TNF-a and prevents its interaction with TNF-a surface receptors. 419: The answer is A (Pharma Guide °"®*' page; 491): Abatacept has very high affinity for CD28 on the T-cell surface, when Abatacept binds to CD28 on the T eell surface (second Signal), it prevents the activation of T cells. ‘ib: The answer is A (Pharma Guide 8" page; 486): Administration of Folinic acid (leucovorin®) 24 hours after each weekly dose or by the use of daily Folie acid (not in the same day; off-days), although this may decrease the efficacy of the Methotrexate by about 10%, but this reduces the severity of adverse effects. ‘Sl:The answer is B (Pharma Guide °%*™! page; 484 - 485): NSAIDs are considered the first line treatment of rheumatoid arthritis, used only to control pain, DMARDs can slow down, the progression of the disease. They are slow-acting drugs, and their effect may ‘ake 6 weeks to 6 months to become evident ‘2:The answer is B (Pharma Guide ***#! page; 487): Hydroxychloroquine seems to be the ‘east oxic among DMARDs and is usually the initial choice. Moreover, — patient, mmunosuppressant drugs are relatively contraindicated because of his frequent _"piratory tract infections. WE : ’ 133Bone and Joint Disorders 483: The answer is D (Pharma Guide "page: 480): The active metabolite (Terituygy of Leflunomide inhibits dihydroorotate dehydrogenase (DHODH) ¢,,, mitochondrial enzyme involved in de novo pyrimidine synthesis), inhibits pyrimidine sym leading 0 decrease in iymphoeyteprotiferation and modulation of afammatg / mechanism is not been fully determined). ‘he answer is C (Pharma Guide °"*™! page; 486): Methotrexate is the ‘initial DM.ARp of choice for most patients. However, it can have dose-related hepatotox, Etanercept, a tumor necrosis factor-a antagonist, would be appropriate in this case 485: The answer is B (Pharma Guide °"*" page, 487): Hydroxychloroquine is extensively tissue-bound, particularly in melanin-containing tissues such as the eyes cary OCULAR TOXICITY. 486: The answer is B (Pharma Guide °*! page; 492): Tofacitinib is an oral inhibitor op for certain types of eytokines 487: The answer is E (Pharma Guide™! page; 486): Probenecid inhibits MTX excretion 488: The answer is A (Pharma Guide "8 page; 486): Leflunomide is prodrug thats ‘metabolized by GI mucosa and liver to active metabolite (A77-1726 or Teriflunomide) 489: The answer is D (Pharma Guide **! page; 487): Leflunomide and Teriflunomidels Pregnancy; category X. Women should wait to become pregnant for at least 2 years att discontinuation of treatment and plasma levels of A771726 should be less than 0.02 mg Or Administer cholestyramine 8 grams, 3 times daily for 11 days, verify plasma leves less than 0.02 mg/L by 2 separate tests at least 14 days apart. If plasma levels are hight than 0.02 mg/L, additional cholestyramine treatment should be considered. 490: The answer is D (Pharma Guide #! page; 490): Methotrexate should be given as lo 4s with Infliximab to decrease or prevent the formation of anti-infliximab antibodies 491: The answer is A (Pharma Guide %*"* page: 492): Tocilizumab is approved ® rheumateld arthritis as monotherapy fst ae theta) or in combination ("i other biologic drugs) with other DMARDs such as Methotrexate ! 492; The answer is B (Pharma Guide °"*'m! page. 498): Local mechanical influences, sete factors, inflammation, and aberrant chondrocyte function leading 10 toss of atti" cartilage. Osteoarthritis most commonly begins with damage to articular cartilage ‘through trauma or other injury, excess joint loading from obesity or other reasot instability or injury of the joint that causes abnormal loading, The chondrocyte bala! between breakdown and resynthesis of cartilage can be fost, and a vieious «Yl increasing breakdown can lead 1o further cartilage loss if 1345 Bone and Joint Disorders £ ‘The answer is B (Pharma Guide °"™ page; 494): There is a link between obesity and 93: TH arthritis, weight loss can decrease the load on a weight-bearing joint and decreased ity osteo ‘moms and di | su teaver is D (Pharma Guide page; 496: Radiologie evaluation (X-2y) can e usually confirm the diagnosis of OA. Loss of joint space and the. presence of new bone {formation oF osteophytes (bone spurs) q gs: The answer is D (Pharma Guide °®"* page; 498): Pharmacological therapy in OA is ‘argeied at relief of pain. For mild or moderate pain, topical analgesics or Paracetamol tan be used if these measures fail, or if there is inflammation, NSAIDs may be useful Low-dose opioid analgesics can be useful for patients who experience no pain relief with | paracetamol, NSAIDs, intra-articular glucocorticoid injections or topical therapy. ‘96: The answer is D (Pharma Guide "*™ page; 497): Patient education, weight loss, physical and occupational therapy, use good posture and start new activities slowly all ofthese are non-pharmacological therapy for osteoarthritis. yt; The answer is A (Pharma Guide °"#™ page; 500): Osteoporosis is a metabolic bone disorder characterized by low bone density, decreasing its strength and resulting in increased risk for bone fracture. 1 The answer is D (Pharma Guide %! page, 501): Vitamin D is a fa-soluble vitamin, | regonsible for increasing intestinal absorption of Calcium, Iron, Magnesium, | Phosphate and Zine | 0%: The answer is A (Pharma Guide °*! page; 506): Cholecalciferol (Vitamin Ds) is | rowinely added to calcium supplements and milk | St: The answer is A (Pharma Guide °"™ page; 503): Estrogen affect balance between resorption and formation, estrogen deficiency increases proliferation, differentiation, and activation of new osteoclasts and prolongs survival of mature osteoclasts. SUL: The answer is D (Pharma Guide °"s™! page; 501): The active form of vitamin D is 14,25. hydroxyvitamin D [14,25(OH): D] (Caleitriol). 5: The answer is A (Pharma Guide! page; 502): Calcitonin Hormone inhibits “steoclastic bone resorption, decreases serum calcium, opposing the effects of Mixa 135Saaa ie Te Bone and Joint Dee ‘Pharma Guide™! page, $03) ee Hormone ( 503: The answer ue Pras of cateium from the IATBE BONES (Bone resgryr pena 1 , ae ice reabsorption of Calcium from kidney 3) enhance absor, osteoclasts 2) ; i Pa tion Calcium from intestine by increasing production of activated vitamin D (Cajcigg al y S04: The answer is D (Pharma Guide *%! page, 504): Dusl-energy X-ray bsorptiomety "(DXA or DEXA) device; isthe gold standard for osteoporosis diagnosis, 505; The answer is A (Pharma Guide °s' page; 509): Bisphosphonates (Alendronaty decrease osteoclastic bone resorption through an increase in osteoclastic apopigg, {programmed cell death) and decrease osteoclast activity. 506: The answer is C (Pharma Guide %! page; 510): The most common Serious side effec of oral bisphosphonates is inflammation (ulcers) and erosions of the esophagus ‘507: The answer is D (Pharma Guide °"*" page; 513): Teriparatide is a recombinant form of human parathyroid hormone (PTH), itis the first drug that stimulates bone formation (other agents inhibit bone resorption. 508: The answer is B (Pharma Guide °#"*! page; 503): Secondary osteoporosis due d endocrine disorders; such as hypogonadism, estrogen deficiency, hyperthyroidism, hyperparathyroidism, acromegaly, Cushing syndrome and diabetes mellitus. 50% The answer is | (Pharma Guide =! page, 03): Secondary osteoporosis due 0 Medications; such as glucocorticoids, anticonvulsants, thyroid replacement drugs, aromatase inhibitors, selective serotonin reuptake inhibitors (SSRIs), heparin (lng {crm) and medroxyprogesterone (Depo-Provera®), AIDS/HIV medications Furosemide, gonadotropin-releasing hormone (GnRH) analogs, thiazolidinedionts (Pioglitazone, rosiglitazone) & proton pump inhibitors (long-term), 510: The answer is B (Pharma Guide sin! is very poor (<1-10%) by passive diffus ‘and other medications (such as Caleium ‘Page; 509): Absorption of oral bisphosphonates ion in the stomach and upper small intestine, food & lron) significantly decrease absorption. c coer Tents Gills tae £14 Hear tacate on ao ino Ralosifene are ate nmenePtusal women without contraindicatons. Calcitonin a apna ‘rnatives but may be less efficacious (especially for non-vertebal actutes). Teriparatide and Denosumab shoul be reserved for patients at high risk those who fail other therapies, Patients at hig! BR r& mar ce peauBone and Joint Disorders Beige ansmer is B Pharma Guide °"*! page; 510); Bisphosphonates are known to cause P ephageal irritation and should be used ‘rosive esophagitis. mm in a patient with a history of 3: The answer is C (Pharma Guide “*™! page: 510): Each oral dose should be taken alone sete m empty stomach [moming] with at least 240 ml of tap water (not coffee, juice, mineral wter of mik) [enteric-coated delayed-release formulation (weekly) needs to be taken with only ~100mL] at least 30 (60 for Ibandronate) minutes before consuming any food, supplements (Calcium) or medications [because bioavailability is very poor and to minimize Gl side effects]. The patient should be remain upright (sitting or standing) for at least 30 minutes (60 for Ibandronate) [10 minimize esophagus ulceration). sid: The answer is E (Pharma Guide vine! nage. 513): Teriparatide is a recombinant form of human parathyroid hormone (PTH), itis the first drug that stimulates bone formation (cther agents inhibit bone resorption), m ‘Page; 512): Calcitonin is a peptide hormone that prownts bone resorption. Salmon caleitonin is available as nasal spray or a parenteral.