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Joints Flashcards

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1
Q

How many osteoporosis related fractures are there per year in the UK?

A

230,000, costing 1.8b

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2
Q

What is the incidence of complications of hip fractures?

A

associated with prolonged hospital stays, 20% die within 6 months due to HAI/VTE etc

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3
Q

How many people does osteoporosis affect ?

A

1 in 2 women over 50

1 in 5 men over 50

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4
Q

What is the thick/outer shell of the bone called?

A

cortex

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5
Q

What is the meshwork inside the bone called?

A

trabecular bone

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6
Q

What do osteoblasts do?

A

Build new bone

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7
Q

What do osteoclasts do?

A

Break down old bone (resorption)

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8
Q

What causes osteoporosis?

A

increased osteoclast activity, decreased osteoblast activity, low peak bone mass

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9
Q

What is the WHO definition of osteoporosis?

A

a generalized skeletal disorder of low bone mass (thinning of the bone) and deterioration in its architecture, causing susceptibility to fracture.

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10
Q

How long does it usually take for bone to be remodelled?

A

100 days

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11
Q

What factors influence bone turnover?

A

hormones (oestrogen, testosterone), cytokines, prostaglandins

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12
Q

What are the signs/symptoms of osteoporosis?

A
  • fracture (usually first presentation)
  • reduced bone density on DXA scan
  • pain, reduced mobility
  • kyphosis (in vertebral fractures)
  • reduction in height
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13
Q

What problems can vertebral fractures cause?

A
  • 10-20% reduction in height
  • indigestion, neck weakness, back pain, loss of mobility

often underdiagnosed

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14
Q

What is the average age for reaching [peak bone mass?

A

25

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15
Q

After what age does bone mass decrease, and by how much?

A

approx 40, 0.5-1% per year

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16
Q

Why do women have accelerated bone loss?

A

oestrogen has protective effects, which is lost after menopause

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17
Q

What and who are DXA scans used for?

A

measure bone density at hip/lower spine to get a T score

used for high risk patients or those with established OP

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18
Q

What T score is the threshold for osteoporosis?

A
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19
Q

What are risk factors for osteoporosis?

A

Hx of fracture / in 1st degree relative
Smoking, alcohol
Low body weight
Female, Oestrogen deficiency
Corticosteroid use- prednisolone ≥ 7.5mg daily for 3/12 or more
White race
Increase age
Low calcium intake
Lack of exercise
Recurrent falls, Dementia, Impaired eyesight
Poor health/ frailty- especially RA, renal disease, liver disease, IBD

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20
Q

What lifestyle changes can be made to help prevent osteoporosis?

A

adequate calcium and vit D
weight bearing exercise
reduce alcohol and smoking
reduce risk of falls, esp in elderly

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21
Q

What medications can be used to manage osteoporosis?

A

Calcium, vitamin D, calcitriol, HRT
SERMS, bisphosphates, calcitonin
strontium, PTH, denosumab

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22
Q

Incidence of osteoarthritis?

A

2% overall, 12% of over 65s

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23
Q

When is the most common onset of osteoarthritis?

A

40-60

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24
Q

Who is more at risk of osteoarthritis?

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A

women, obese people

25
What are the clinical features of osteoarthritis?
- joint pain, worsened on movement and at end of day - possible swelling - most common in knee, hands, lumbar and cervical spine - early morning stiffness up to 30 mins
26
What is the pathogenesis of osteoarthritis?
- cartilage roughens and thins - thickening of underlying bone - formation of osteophytes - thickening/inflammation of synovium - thickening and contraction of ligament
27
What are the goals of osteoarthritis management?
reduce pain, improve mobility, minimise joint deformity,
28
What non-pharmacological options are there for osteoarthritis?
weight reduction, physiotherapy, exercise plan, heat packs, occupational therapy review, psychological support, surgery
29
What pharmacological options are there for osteoarthritis?
simple analgesics, NSAIDs, corticosteroids, chondroprotective agents
30
Incidence of rheumatoid arthritis?
1-3% of population, 3:1 female to male | onset most common 30-50s
31
What are the clinical features of rheumatoid arthritis?
- slow, progressive, symmetrical polyarthritis - pain & stiffness in small joints of hands and feet - early morning stiffness
32
What joints does rheumatoid arthritis involve?
wrists, shoulders, elbows, knees, ankles
33
What are some extra-articular symptoms of rheumatoid arthritis?
Sjorgens syndrome, vasculitis, neuropathy, subcutaneous nodules, lymphadenopathy, cardiovascular disease, depression, respiratory disease
34
What are the outcomes for people with rheumatoid arthritis?
75% have some joint pain, swelling and flare ups 20% will always have mild RA 5% will develop severe extensive disability
35
What is the pathogenesis of rheumatoid arthritis?
- lymphocytes infiltrate synovial membrane, causing inflammation and thickening - formation of pannus over cartilage causes erosion into bone - eventual degeneration of cartilage and joint
36
What are the goals of management of rheumatoid arthritis?
- relief of pain/inflammation - prevention of joint damage - preservation/improvement of functional ability - maintenance of lifestyle
37
What pharmacological options are there for management of rheumatoid arthritis?
- NSAIDs - analgesics - steroids - conventional DMARDs - biological DMARDs
38
What is a DMARD?
Disease Modifying Anti-Rheumatic Drug
39
Difference between osteoarthritis and rheumatoid arthritis: joint involvement?
OA: often limited to one joint RA: symmetrical and many joints involved
40
Difference between osteoarthritis and rheumatoid arthritis: effect of movement?
OA: pain worsens on movement and as day progresses RA: improves with movement
41
Difference between osteoarthritis and rheumatoid arthritis: stiffness?
OA: wears off over the day RA: worsens over the day
42
Difference between osteoarthritis and rheumatoid arthritis: swelling?
OA: may be swelling RA: usually swelling
43
First recommendations for adults newly diagnosed with rheumatoid arthritis?
offer first line conventional DMARD - methotrexate, leflunomide or sulfasalazine - consider hydroxychloroquinine as alternative for mild diseae bridging therapy of oral, IM or IA steroid NSAIDs/analgesics max dose
44
Step up therapy for rheumatoid arthritis if initial treatment is not effective?
additional cDMARDs
45
Treatment options if cDMARDs are not effective?
DAS28 score of greater than 5.1 | Biolgoic DMARDs - Sarilumab, with methotrexate (can also be used as monotherapy)
46
What is the DAS?
Disease activity score - greater than 5.1 = severe
47
Advantages of biologic DMARDs over conventional ones?
- can be combined with other drugs - quicker response to treatment - better tolerated - may reverse joint damage
48
Disadvantages of biologic DMARDs over conventional ones?
- cost - infection risks - self administration, may be an issue
49
What screening treatments must be done before starting treatment with biologic DMARDs?
- TB, HIV, Hep A, Hep B - cancer history - recent travel abroad - Chest xray - History of heart disease - exclude pregnancy
50
Important counselling points for hydroxychloroquinine
- how it will help symptoms - up to 3 months to work - dose - GI side effects - mild - if rash to stop immediately - eye checks needed
51
Important counselling points for methotrexate?
- how it will help symptoms - up to 3 months to work - dosing once weekly - folic acid and role - side effects: nausea, mouth ulcers, hair loss (rare), increased infection risk, liver toxicity (limit alcohol) - get vaccinations but avoid live ones - don't get pregnant - interactions: aspirin, trimethoprim, septrin (co-trimoxazole) - regular blood tests
52
Important counselling points for sulfasalzine?
- how it will help symptoms - up to 3 months to work - indigestion - rash - stop immediately - may discolour urine and contact lenses - pregnancy - it's safe - regular blood tests - vaccinations but avoid live ones
53
Counselling points for alendronate?
- role in helping bone health - once a week - take at least 30 mins before breakfast - full glass of water - stay upright (dont lie down) for at least 30 mins - see GP if throat discomfort or indigestion
54
What alternatives are there for osteoporosis patients if alendronate is not effective or tolerated?
- other oral bisphosphonate, : risedronate, ibandronate - yearly infusion of risedronate, esp if GI effects with oral - Denosumab is next option- sc injection twice a year, inhibits RANK ligand protein which is involved in stimulating osteoclasts activity
55
Lifestyle advice to patients with osteoporosis?
Calcium rich diet/supplements of ca and vit d3, weight bearing exercise
56
Mechanism of rituximab?
inhibits B cells
57
Mechanism of tocilizumab?
inhibits interleukin
58
Mechanism of abatacept?
inhibits T cells

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