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Therapeutics > E2 L10: Osteoarthritis > Flashcards

E2 L10: Osteoarthritis Flashcards

1
Q

Osteoarthritis

A

Degenerative changes that occur in cartilage and the associated bone
-Characterized by increased destruction and subsequent proliferation of cartilage and bone

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2
Q

Factors affecting osteoarthritis:

A

Gender - more common in women
Hormones
Athleticism
Weight
Improper shift (too much weight on one side)
etc.

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3
Q

Incidence

A

Most common in older patients (85% of pt > 75 years)
Severity increases w/age
More common in females

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4
Q

Joints involved

A

Distal interphalangeal joint (fingers)
Hips
Knees

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5
Q

Risk factors

A

Increased age
Obesity
Congenital defects
Muscle weakness
Female
Repetitive stress
Major joint trauma
Heredity

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6
Q

Clinical manifestations

A

Joint pain
AM stiffness
Crepitus (cracking we hear when moving joints)
Inflammation
Muscle atrophy
Asymmetric involvement

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7
Q

Clinical manifestations cont.

A

No systemic symptoms (associated with joints)
Instability of weight bearing joints

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8
Q

Finger joint names

A

Heberden’s nodes
Bouchard’s nodes

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9
Q

Is there a cure for osteoarthritis?

A

No - surgery required

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10
Q

Common complaints

A

I have pain when I wake up
My knee is tender or sore after overuse
I feel pain in my knee even when I am not active
Getting up from a chair, out of a car, or going up or down stairs is difficult
I hear a crackling sound in my knee when I move
I experience a grating feeling in my knee when I move
The area around my knee is red and swollen

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11
Q

Goals of therapy w/osteoarthritis:

A

Relief of pain and discomfort
Maintain function of joint and strength

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12
Q

Treatment of OA - non drug therapy

A

Physiological support
Education (are they working out properly)
Rest
Physical activity / exercise
Heat/ice
Physical therapy
Occupational therapy
Weight loss

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13
Q

Treatment of OA - drug therapy

A

Topical therapy
Oral agents
Supplements
Injectables

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14
Q

Always start with non-drug therapy or drug therapy?

A

Non-drug

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15
Q

Two types of joints to treat for osteoarthritis

A

Hands
Knees and hips

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16
Q

Tx of OA: Topical therapy

A

Menthol
Camphor
Oil of wintergreen (methyl salicylate)
Topical, counterirritant
-Creates tingling in joints to distract from pain
Dose: apply to affected area TID-QID - not long acting
No systemic - no side effects

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17
Q

Topical therapy ex.

A

Bengay
Icy hot
Salonpas

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18
Q

Tx of OA: Topical therapy: Capsaicin Cream (Zostrix)

A

MOA: depletes substance P (pain receptor in skin)
Dose: apply sparingly to affected joints TID-QID
Wait 2-4 weeks of continuous application to evaluate results
Adverse effects: burning, stinging, and redness which dissipates w/continued use
Counterirritant

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19
Q

Tx of OA: Topical therapy: Diclofenac Gel 1% - Voltaren Gel

A

MOA - local inhibition of COX2 enzymes
Dose: Apply 2-4g to affected joint QID (2 to hands, 4 to knees)
Max 16g to any one join daily (total body max 32 grams/day)
NOT recommended in combo with NSAIDs
Adverse effects: burning, itching pain and rash

20
Q

Tx of OA: Topical therapy: Diclofenac Topical Solution % - Pennsaid

A

For knee only
Dose:
40-drops (40mg) to each knee QID
Apply 10 drops at a time
2 pumps (40mg) twice daily
Local reaction most common adverse effect
-Not OTC
Only approved for knee
Hardly used

21
Q

Acetaminophen (Tylenol)

A

MOA: not well defined, but is thought to involve the inhibition of prostaglandin synthesis in the CNS
Dose: Max 3-4 g per day
Two-four week trial

22
Q

Why can you only take 3-4g of tylenol?

A

Increased chance of liver toxicity

23
Q

Acetaminophen: Risks

A

Patient at risk for hepatotoxicity: Heavy EtOH intake
Pre-existing liver disease
Monitor ALT/AST annually if on routine doses (be mindful about hidden acetaminophen in combo products)

24
Q

Tylenol Extra strength dosing: 500mg

A

Adults and children 12 years of age and over: Take 2 caps every 6 hours while symptoms last
DO NOT take more than 6 caps in 24 hours unless directed by a doctor

25
Q

NSAIDs point to remember

A

No two patients respond the same
If patient does not respond - switch to alternative NSAID

26
Q

NSAID MOA

A

Park’s lecture

27
Q

NSAID therapy (Analgesic vs Anti-inflammatory dose)

A

Analgesic - Naproxen 220mg q 8-12 hrs
Anti inflammatory: Naproxen 440mg q8-12
Most patients respond to analgesic response
1-2 week trial for pain and 2-4 week trial if inflammation exists

28
Q

NSAID therapy: adverse effects

A

GI upset, ulcers, bleeding, renal dysfunction, increase BP, increased risk of stroke, MI, and death

29
Q

NSAIDs - at greatest risk for adverse effects:

A

Dose dependent
Age . 75
H/o GI bleed
h/o of PUD
Anticoagulants
Antiplatelet
Glucocorticoids

30
Q

NSAID therapy: patients at greatest risk for nephrotoxicity

A

Nephrotoxicity: rapid deterioration in kidney function
-Patients with:
CHF
HTN
Renal Disease
Dehydration

31
Q

NSAID therapy: patients at greatest risk for cardiovascular AE’s

A

CHF
CVD

32
Q

Monitoring NSAIDS: what to look for

A

Blood pressure
Signs of edema or weight gain
SCr - every 3 months
Hgb / Hct - every 6-12 months
signs of dehydration

33
Q

COX-2 inhibitors

A

COX-2 inhibitors
Celebrex
Dose: 100 - 200 mg orally daily or bid
Lower incidence of GI bleeding

34
Q

Potential risks associated with COX-2 inhibitors

A

Increased risk of CV disease
Same effects on renal function
increase cost of therapy

35
Q

Combination Products:

A

NSAID + PPI
-Vimovo - naproxen + esomeprazole
NSAID + misoprostol
-Arthotec - diclofenac + misoprostol
NSAID + H2 antagonist
Duexis - ibuprofen + famotidine

36
Q

Know guidelines for NSAID use in OA

A

-

37
Q

Opioid Analgesics:

A

Used PRN for breakthrough pain
Dosing: start low and go slow
Use long acting (SR) and short acting (IR)

38
Q

Adverse effects of Opioid analgesics

A

Nausea
Somnolence (sleepy)
Constipation
Dizziness
Abuse potential

39
Q

Tramadol (Ultram)

A

MOA: Affinity for µ receptor
Dose:
25-50 mg every 4-6 hrs
Titrate to 200-300 mg per day
Adverse effects:
Nausea, vomiting, dizziness, constipation

40
Q

Duloxetine (Cymbalta)

A

Adjunct medication
Dose: 30mg/day x 1 week
Max dose: 60mg daily
AVOID with tramadol
Adverse effects: GI

41
Q

OTC supplement Glucosamine/Chondroitin

A

MOA: stimulates proteoglycan synthesis
Dose; 500 mg PO TID (glucosamine)
400 mg PO TID (chondroitin)
Slow onset (4 weeks) - 3 month trial is adequate
Adverse effects: gas, bloating, cramping, nausea, and increased bleeding risk (glucosamine)

42
Q

Treatment of OA: Intra-Articular Corticosteroid Injections:

A

Only used for isolated joints
No more than every 3-6 months
Actual injection can be quite painful, repeat injections can cause joint damage
Peak pain relief in 7-10 days

43
Q

Treatment of OA: Hyaluronate Injection (Synvisc, Synvisc One)

A

MOA: temporary increase in viscosity
Dose:
Synvisc: injected into knee weekly for 3 weeks
Synvisc one: injected into knee once
Max benefit in 8-12 weeks

44
Q

What is hyaluronate injection used for

A

Used for patients who do not tolerate other treatments or are not candidates for surgery
Only local adverse effects (minor swelling)

45
Q

Treatment of OA: Joint Replacement Surgery

A

Relieves pain at rest
Restores function to the joint
Last 10-15 years
Newer materials last longer

46
Q

Monitoring parameters with joint replacement therapy

A

Pain (at rest)
Joint stability and function
Risk of fall
Range of motion
X-rays
Degree of disability
Weight
ADRs from medications
Compliance with non-drug measures
QOL issues

47
Q

Future/Alternative treatments

A

Acupuncture
Strategies/targets: cartilage, synovial membrane, subchondral bone
DMOAD - disease modifying osteoarthritis drugs
Stem cell therapy

Therapeutics (49 decks)

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