Arthritis, Gout, and Muscle Relaxants Flashcards
(35 cards)
Rheumatoid arthritis cause, common sites, characteristics, and sxs
- cause: systemic inflammatory disorder
- common sites: hands, wrists, feet
- characteristics: deforming polyarthritis, inc CRP/ESR + RF
- sxs: fatigue, malaise, diffuse musculoskeletal pain, morning stiffness
osteoarthritis cause, common sites, characteristics, and sxs
- cause: degeneration of cartilage, MOST COMMON FORM OF ARTHRITIS
- common sites: distal and proximal interphalangeal, first carpometocarpal, knees, hips, cervical, lumbar spine
- characteristics: sense of grating or crackling in joints
- sxs: deep aching localized pain to involved joint, morning stiffness and stiffness at the end of the day
gout cause, common sites, characteristics, and sxs
- cause: deposition of UA crystals in joints
- common sites: great toe
- characteristics: UA > 7mg/dL
- sxs: severe pain associated with minimal touching of affected area
osteoarthritis
- most common joint disease
- Failure of a movable, synovial-lined joint due to thinning of joint surface
- Weakening and splitting of cartilage
classification of osteoarthritis
- Primary (idiopathic) – no predisposing factor present
- Secondary – due to another cause: Trauma, congenital/developmental, metabolic, rheumatoid arthritis
risk factors for osteoarthritis
Age, female gender, race, obesity, occupation-related repetitive injury, physical trauma, congenital/developmental defects, metabolic/endocrine disease
signs and symptoms of osteoarthritis
-Pain: Early osteoarthritis – localized, increased with activity and resolving with rest; Late osteoarthritis – pain at rest
-Stiffness: After periods of inactivity, morning stiffness usually lasting
< 30 minutes
-Bony enlargement
-Crepitus on motion
-Limited joint motion
-Radiographic evidence
most common joints affected by osteoarthritis
- Hips
- Distal interphalangeal (DIP) and;
- Proximal interphalangeal (PIP) joints of the hands
rheumatoid arthritis
- Symmetric erosive inflammatory synovitis involving multiple organ systems
- Pathophysiology: Inflammatory cytokines and chemokines (interleukin-1 [IL-1], IL-6, IL-10), tumor necrosis factor-alpha [TNF-a] (Responsible for synovial tissue and fluid inflammation, cartilage and bone damage, and system disease)
rheumatoid arthritis signs and sxs
- Early – fatigue, weight loss/loss of appetite, low grade fever, joint pain
- Labs: increased ESR (erythrocyte sedimentation rate), + Rheumatoid factor, + Antinuclear antibodies, Elevated CRP (C-reactive protein)
American rheumatism association criteria
a. Morning stiffness lasting at least one hour before improvement
b. Arthritis >3 joint areas: PIP, metacarpophalangeal joint [MCP], wrist, elbow, knee, ankle, and metatarsophalangeal [MTP] joint)
c. Arthritis >1 hand joint: wrist, MCP, or PIP
d. Symmetrical arthritis (involvement of same joint on both sides of the body)
e. Rheumatoid nodules over bony prominences
f. Positive serum rheumatoid factor
g. Radiography with soft-tissue swelling, bony decalcification or erosions
h. 5 out of the 7 signs and symptoms above must be present for diagnosis and;
i. a through d must be present > 6 weeks
duration of pain, joint location, and labs for osteoarthritis vs. rheumatoid arthritis
- duration of pain: <30mins OA; >30-60mins RA
- joint location: DIP, PIP, hips (may be asymmetrical) OA; PIP, MCP, wrist, elbow, MTP (symmetrical involvement) RA
- labs: no change in ESR OA; elevated ESR RA
definition of improvement or adequate response to therapy
- > 20% improvement in tender joint count (out of at least 28 joints) and
- > 20% improvement in swollen joint count (out of least 28 joints) and
- > 20% improvement in 3 of the following: Patient pain assessment, Patient global assessment, Physician global assessment, Patient self-assessed disability, Acute-phase reactant (ESR, CRP, etc.)
psoriasis and psoriatic arthritis
- Psoriasis - common skin disease affecting 1.4 to 4.6% of US population
- Prevalence is influenced by ethnicity (blacks 1.3% vs. white 2.5%) and geographic factors (cooler vs. warmer climates)
- Psoriatic Arthritis (PsA) affects 5-20% of patients with psoriasis (Wide clinical spectrum from mild to mutilating.)
PsA vs. RA
-Differs from RA – asymmetric (60%), axial involvement, and it has components of both enthesitis and synovitis
-Characteristics include nail pitting, yellowish nail discoloration, arthritis mutilans.
-Although two separate entities, therapy is similar.
(enthesitis = the sites where tendons or ligaments insert into the bone; AM = general to severe derangement of any joint)
ankylosing spondylitis
Cervical spondylosis is a disorder that results from abnormal growth of the bones of the neck and degeneration and mineral deposits in the cushions between the vertebrae. Progressive neck pain is a key indication of cervical spondylosis. It may be the only symptom in many cases. Examination often shows limited ability to bend the head toward the shoulders and limited ability to rotate the head. The goal of treatment is relief of pain and prevention of permanent spinal cord and nerve root injury
- Often begins between ages 20 and 40, but may begin before age 10
- Risk factors include: Family history of ankylosing spondylitis, Male gender (males > females)
- Tests may include: CBC, ESR, HLA-B27 antigen, X-rays of the spine and pelvis
Arthritis nonpharmalogical treatment and goals
- Goals: Reduce pain, Maintain or improve joint motion, Minimize decline in function
- Non-pharmacologic therapy: Patient education and self-management programs, Weight loss, Occupational and physical therapy
Arthritis pharmacologic therapy
-Must be combined with non-pharmacologic treatment, Acetaminophen (Tylenol®) – Osteoarthritis ONLY
- Regimen: Up to 4 grams/day, reduce dose by 50-75% in renal or hepatic failure or alcohol abuse
- Advantages: Effective for mild to moderate pain with low risk for side effects
- Disadvantages: Not effective for pain associated with inflammation, must use with caution for patients with hepatic dysfunction, must monitor INR with use of high doses
- Place in therapy: Mild-to-moderate pain, first-line
NSAIDs and COX-2 inhibitors regimen, advantages, disadvantages, place in therapy
- Regimen: Refer to Pain Medications and NSAIDs lecture
- Advantages: Effective for moderate-to-severe pain
- Disadvantages: GI side effects, renal dysfunction, drug interactions
- Place in therapy: Moderate-to-severe pain, use if no response to acetaminophen
COX-2 inhibitors
- celecoxib (celebrex) 100-200mg PO qd to bid
- meloxicam (Mobic) 7.5-15mg qd
Nonacetylated salicylates regimen, advantage, disadvantages, place in therapy
-Regimen: Salsalate 500-750 mg PO BID
Choline magnesium trisalicylate 500-750 mg PO TID
-Advantages: Effective for moderate-to-severe pain, Less risk for GI toxicity, Does not affect platelet aggregation
-Disadvantages: Potential for GI side effects, renal dysfunction
-Place in therapy: Moderate-to-severe pain, Patients not responsive to acetaminophen, Alternative to NSAIDs due to adverse effects or potential for drug interactions (warfarin)
Intraarticular glucocorticoids regimen, advantages, disadvantages, place in therapy
- Regimen: Methylprednisolone 4-80 mg based on size of joint every 1-5 weeks
- Advantages: Effective for knee OA
- Disadvantages: Not studied in hip OA, but relatively common
- Place in therapy: Adjunctive
Intraarticular hyaluronic acid: drugs, place in therapy, side effects, advantages, disadvantages
Drugs: Hyalgan® (20 mg intra-articular Q week x5 weeks), Synvisc® (16 mg intra-articular Q week x3 weeks), Supartz® (25 mg intra-articular Q week x5 weeks), Euflexxa® (20mg intra-articular Q week x 3), Gel-One® (30mg intra-articular once)
- Place in therapy: Moderate-to-severe pain for osteoarthritis only (knees)
- Side effects: Injection site pain, Knee swelling, Warmth, redness or itching injection site, Occasionally GI complaints and headache
- Advantages: Duration of relief may last up to 6 months
- Disadvantages: Delayed onset of action, not approved for hip OA
Biologic DMARDs
- TNF-a inhibitors: adalimumab, certolizumab, etanercept, golimumab, infliximab (-dyyb, -abda)
- interlukin: anakinra, guselkumab, ixekizumab, secukinumab, tocilizumab, usetinumab
- others: apremilast, abatacept, rituximab, tofacitinib, vedolizumab
