Lecture 20+21: Osteoarthritis

Question 1

Osteoarthritis pathophysiology

Answer 1

-degenerative changes that occur in cartilage and the associated bone
-inc destruction and proliferation

Question 2

Osteoarthritis incidence

Answer 2

-older
-most-common joint disease
-worsens w age
-more common for women

Question 3

Joints implicated in osteoarthritis

Answer 3

-distal interphalangeal joint
-hips
-knees

Question 4

risk factors

Answer 4

-age
-weight
-defects
-muscle weakness
-woman
-stress
-trauma
-hereditary

Question 5

Symptoms

Answer 5

-joint pain
-stiffness in morning
-crepitus
-inflammation
-muscle atrophy
-asymmetric involvement

Question 6

Other manifestations

Answer 6

-no symptoms
-instabiliity of weight bearing joints
-herberden’s nodes
-bouchard’s nodes

Question 7

Osteoarthritis first line treatment

Answer 7

-acetaminophen
-topical NSAIDs
-intramuscular corticosteroids

Question 8

osteoarthritis second line treatment

Answer 8

-opiods
-surgery
-duloxetine
-intraarticular hyaluronates

Question 9

Non-pharmacological treatment of osteoarthritis

Answer 9

-psychological support
-education
-rest
-exercise
-heat/ice
-physical therapy
-occupational therapy
-weight loss

Question 10

Topical therapy

Answer 10

-menthol/camphor/wintergreen
-capsaicin cream
-diclofenac gel or topical solution

Question 11

Menthol/Camphor/oil of wintergreen

Answer 11

-topical
-counterirritant
-aaa TID-QID

Question 12

Capsaicin cream

Answer 12

-depletes substance P
-aaa TID-QID
-wait 2-4 weeks for full effect

Question 13

Capsaicin cream adverse effects

Answer 13

-burning
-stinging
-redness
-symptoms go away with use

Question 14

Diclofenac Gel (Voltaren Gel)

Answer 14

-COX-2 inhibition
-aaa 2-4g QID
-max 16g qd
-dont use in combo w systemic NSAID

Question 15

Diclofenac gel adverse effects

Answer 15

-pruritus
-burning
-pain and rash

Question 16

Diclofenac gel application

Answer 16

-measure
-apply
-massage

Question 17

Diclofenac topical solution (pennsaid)

Answer 17

-for KNEE only
-40 drops each knee QID or
-apply 10 drops at a time or
-2 pumps BID

Question 18

diclofenac solution adverse effects

Answer 18

-local reaction

Question 19

Acetaminophen

Answer 19

-thought to inhibit prostaglandin synthesis in the CNS
-3-4g qd
-2-4 weeks

Question 20

Acetaminophen cautions

Answer 20

-patients at risk for hepatotoxicity (liver disease and alcoholics)
-monitor ALT/AST annually if on routine dose

Question 21

NSAIDs

Answer 21

-COX inhibitors
-analgesic dose lower than anti-inflammatory dose
-1-2 weeks for pain
-2-4 weeks for inflammation

Question 22

NSAID therapy side effects

Answer 22

-GI
-ulcers
-bleeding
-renal dysfunction
-inc BP
-inc risk of stroke MI and death

Question 23

NSAID at risk population

Answer 23

-dose dependent
-age
-GI bleed
-PUD
-anticoagulants
-antiplatelet
-glucocorticoids

Question 24

patients at greatest risk for nephrotoxicity from NSAID

Answer 24

-CHF
-HTN
-ESRD
-dehydration

Question 25

patients at greatest risk for cardiovascular adverse effects from NSAID

Answer 25

-CHF -CVD

Question 26

Monitoring NSAIDs

Answer 26

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

Question 27

COX-2 inhibitors

Answer 27

-celebrex -100-200mg PO qd or BID -lower incidence of GI bleeding

Question 28

Risks w COX-2 inhibitors

Answer 28

-inc risk of CVD -same effects on renal function -inc cost of therapy

Question 29

Combination products

Answer 29

-NSAID + PPI -NSAID + misoprostol -NSAID + H2 antagonist

Question 30

NSAID + PPI

Answer 30

-naproxen + esomeprazole

Question 31

NSAID + misoprostol

Answer 31

-diclofenac + Misoprostol

Question 32

NSAID + H2 ANTAgonist

Answer 32

-ibuprofen + famotidine

Question 33

SLIDE 44

Answer 33

SLIDE 44

Question 34

Opioid Analgesics

Answer 34

-PRN for pain -start low and go slow -nausea, somnolence, constipation, dizziness

Question 35

Tramadol

Answer 35

-affinity for u receptor -25-50mg q4-6h -titrate to 200-300mg/day -nausea, vommiting, constipation, dizziness

Question 36

Duloxetine

Answer 36

-adjunct medication -30mg/day once a week -max 60mg in one day -avoid w tramadol -GI effects

Question 37

Glucosamine/Chonroitin

Answer 37

-OTC -stimulates proteoglycan synthesis -500 mg PO TID (G) -400 mg PO TID (C) -slow onset (4 weeks)- 3 month trial

Question 38

Glucosamine adverse effects

Answer 38

-gas -bloating -cramping -nausea -inc bleeding risk

Question 39

Intra-articular corticosteroid injections

Answer 39

-only used for isolated joints -no more than every 3-6 months -injection hurts -repeat injection can cause damage -peak relief in 7-10 days

Question 40

Hyaluronate Injection

Answer 40

-temp inc viscosity -inject into knee -max relief 8-12 weeks -for patients who do not tolerate treatments or are not candidates for surgery -only minor swelling adverse effect

Question 41

Joint replacement surgery

Answer 41

-relieves pain at rest -restores function to joint -lasts 10-15 years

Question 42

Monitoring parameters

Answer 42

-pain -joint stability and function -risk of fall -range of motion -X-rays -degree of disabiliity -weight -ADRs from medications -complicance w non-drug measures -QOL issues

Question 43

Alternative treatments

Answer 43

-acupuncture -target cartilage, synovial membrane, subchondral bone -DMOAD (disease modifying osteoarthritis drugs) -stem cell therapy