What are some pharmacological treatment goals for osteoarthritis patients
- Decreased pain
- Decreased damage
- Increase/maintain function
- Increase/maintain QOL
- Increase /maintain work productivity
What are some pharmacological treatment goals for osteoarthritis physicians
- Same as patient PLUS - Prevent comorbidities - Prevent complications - Delay need for surgery
What are some pharmacological treatment goals for inflammatory arthritis patients
Same as OA: - Decreased pain - Decreased damage - Increase/maintain function - Increase/maintain QOL - Increase /maintain work productivity PLUS: - Stop joint swelling, pain, stiffness, fatigue, damage (=remission)
What are some pharmacological treatment goals for inflammatory arthritis physicians
Same as patient PLUS: - Prevent comorbidities - Prevent complications - Delay need for surgery - Induce remission where possible
Why is medication adherence important for physiotherapy
Good disease control:
- Better participation in PT
- Increase physical activity
- ADLs
- Work productivity
- life roles
What is the result of poor medication adherence
major cause of disease progression + disability, morbidity, health care cost
___/5 RA patients take medications as prescribed at >80% adherence
1/5
What is the physiotherapists role in medication adherence
- Educate on importance of pain & disease control for their quality of life and function
- Redirect to pharmacist/MD for ore detailed information or follow up
- Reassure
What are the 3 categories of barriers to medication adherence
- Patient-related factors
- Drug-related factors
- Other factors
What are the patient-related factors which may be a barrier to medication adherence
socio-demographics, psycho-social profile, comorbidities, cognitive ability, health literacy = health beliefs
What are the drug-related factors which may be a barrier to medication adherence
- Number of drugs taken
- Adverse effects
- Administration regimens
What are the “other factors” which may be a barrier to medication adherence
- Patient-prescriber relationship
- Access to medication
- Social support
What are the two main groups of arthritis medications
- analgesia
- disease modifiers
What is the goal of analgesia use in arthritis treatment
- Control pain (& some inflammation)
What are some examples of analgesia used in arthritis treatment
- Acetaminophen/paracetamol
- NSAIDs
- Steroids (short course)
- Drugs for off-label use (central or neuropathic pain)
- Opioids
What is the goal of the use of a disease modifier in arthritis treatment
Control disease by modifying or suppressing immune inflammatory response
What are some examples of disease modifying drugs used to treat arthritis
- NSAIDs (only in spondylitis)
- Corticosteroids
- Disease modifying antirheumatic drugs (DMARDs)
- Biologic disease modifying antirheumatic drugs (biologics or biologic DMARDs
What is a brand name of acetaminophen
tylenol
What is the function, use, and precaution for treatment with acetaminophen
Function: decrease pain, reduce fever
Use: 1st line for OA, control of mild to mod joint pain. 1-2 hours to take effect
Precautions: Tolerated better than NSAIDS and safe in elderly with comorbidities. Safe to take in combo with NSAID or other arthritis meds. Risk of liver failure if too much or in combo with alcohol
What is the function, use, and precaution for treatment with NSAIDS
Function: Decrease pain, swelling, stiffness, fever
Use:
- Primariy is OA, spondylitis for joint pain + inflammation.
- High NSAID intake slows new bone formation in individuals with hight c-reactive protein only
- Analgesia 30-60mins, steady state after 2 days
- Few days 1/week for optimal anti-inflammatory effects
Precautions:
- Raises BP
- Increased cardiovascular event risk (non-aspirin NSAIDS), but the risk is lower than smoking or hypertension
- Make sure not combining 2 types together
- Topical have similar benefits and safer
What are some types of NSAIDS
Aspirin, ibuprofen, naproxen
What is the function, use, and precaution for treatment with Serotonin-norepinephrine reuptake inhibitory
Function: Second-line analgesis agen where no/partial response to acetaminophen/NSAIDs. Takes effect within 1 week
Use: neuropathic pain in OA
Precations: Side effects include dizziness/light headedness. may raise BP
What is the function, use, and precaution for treatment with Opioids
Function: Decrease pain
Use:
- Second line Rx for moderate to severe OA pain; not commonly used as often risk>benefit
- No data on benefit for inflammatory arthritis past 6 weeks
- work within 1 hour
Precautions:
- Side effects can include drowsiness, dizziness, constipation
- Opioid tolerance with prolonged use can sensitize to pain
- Risk of dependence with chronic use
What are opioids prescribed for
- Acute/chronic pain resulting from disease, surgery or injury
- Moderate to severe coughs & diarrhea
- To treat addiction to other opioids such as heroin or oxycodone
- Controlling pain in terminal illness
What can long-term use of opioids lead to
- Increased tolerance to the drug, so that more needed to produce same pain relieving effect
- Dependence
- Withdrawal symptoms
What are the 1st and 2nd lines of treatment for disease modifiers
1st - DMARDS
2nd - Biologics
What are adjuncts to treatment with disease modifiers
Corticosteroids
Analgesics
NSAIDS
What is the function, use, and precaution for treatment with DMARDs (Methotrexate)
Function: Disease modifying anti-rheumatic drug. Prevent joint damage by suppressing inflammatory pathways. Can take up to 3 months for full effect
Use: IA: RA, juvenile idiopathic arthritis, psoriatic arthritis, lupus
Precautions: Side effects can include nausea and faitgue day after with methotraxate
What can improve the fatigue and nausea felt with methotrexate
Taking folic acid
What are the two ways you can take methotrexate
oral tablets
subcutaneous injection
What is the function, use, and precaution for treatment with biologics
Function: Same as DMARDs; reserved for people who have not responded adequately to conventional DMARDs and for those who cannot tolerate DMARDs in doses large enough to control inflammation
Use: RA, axial spondylitis, etc.
Precautions:
- Increased risk of serious infections
- Sterile technique if dry needling, keep environment hygienic
Are biologics simple or complex proteins
complex
Are biologics more or less variable than chemically synthesized drugs
more
What is a biosimilar
a copy of a biologic medicine that is similar, but not identical to the original medicine
What is the criteria to be called a biosimilar
Need to demonstrate structural and functional similarities with comparable pharmacokinetic and pharmacodynamic properties to the reference product (in terms of safety, purity, potency, efficacy)
When do biosimilars enter the market
Subsequent to a previously autorized version whose patent has expired
What is the function, use, and precaution for treatment with corticosteroids
Function:
- Most efficacious anti-inflammatory drug available
- Oral takes effect within 1-4 days
- Injections 24-48hours rest joint
Use:
- OA - joint injection
- Inflammatory art - oral; injection
Precautions (>2months oral use:)
- Decrease bone density & risk of fracture with long term use
- Increase blood sugars
- Increase muscle wasting
- Increase infection risk
- Small risk of avascular necrosis
- Dont combine with alcohol or large amounts of NSAIDS
- Risk of GI ulceration
What is the relationship between corticosteroids and tendon ruptures
- IN vitro corticosteroids can decrease cell proliferation and collagen synthesis, collagen disorganization & necrosis
- BUT, underlying tendinopathy, mechanical failure, cartilage erosion often already present in inflammatory arthritis and OA
- if dont control joint or tendon inflammation, risk of joint damage/tendon rupture
Are corticosteroids injected right into the tendon
no
is acetaminophen most commonly used for OA, RA, or AxSpA?
OA
Can use for RA as well
are NSAIDs most commonly used for OA, RA, or AxSpA?
OA and AxSpA
Can also use for RA
are corticosteroids most commonly used for OA, RA, or AxSpA?
RA
are Conventional DMARGS most commonly used for OA, RA, or AxSpA?
RA
are Biologics/biosimilar DMARDs most commonly used for OA, RA, or AxSpA?
RA and AxSpA
Are corticosteroid intra-articular injections most commonly used for OA, RA, or AxSpA?
OA
RA
and AxSpA in Si joint and peripheral joints
