NSAIDS, RA and OA

Question 1

4 Goals of NSAIDS

Answer 1

1. decrease inflammation
2. reduce fever
3. relieve mild-moderate pain
4. inhibit platelet aggregation (anticoagulation)

Question 2

What is the original NSAID?

Answer 2

Aspirin

Question 3

Is Acetaminophen an NSAID?

Answer 3

No, Tylenol does not decrease inflammation or have anticoagulation properties

Question 4

What are Prostaglandins?

Answer 4

A hormone that helps to regulate cell function under normal conditions and pathological conditions- all cells expect RBCs can produce them

Question 5

How do NSAIDs work?

Answer 5

During an injury there is an increase in prostaglandin production. NSAIDs Interfere with the synthesis of prostaglandins by inhibiting the COX enzyme (this enzyme is the first step in the synthesis of prostaglandin)

Question 6

Which COX enzyme is considered more harmful?

Answer 6

COX-2. It produces prostaglandins that mediate pain and other aspects of the inflammatory response primarily in injured cells. However, NSAIDS are non-selective and thus block COX-1 and COX-2.

Question 7

Why is it beneficial to take a regular aspirin?

Answer 7

-decreases chances of colorectal cancer
-prevent GI cancers and non-GI cancers
-prevents tumor growth by inhibiting COX-2 enzyme which could cause abnormal cell division in these tissues

Question 8

Side effects of NSAIDS

Answer 8

-GI damage (most common)
-cardiovascular issues
-liver problems
-kidney problems
-associated with Reye Syndrome
-inhibits bone healing

Question 9

What is Aspirin Intoxication or Positioning? What are the Symptoms?

Answer 9

Aspirin overdose
-HA
-tinnitus
-difficulty hearing
-confusion
-GI distress
-metabolic acidosis

Question 10

Is Aspirin beneficial for those with a fracture or s/p spinal fusion?

Answer 10

No! Aspirin inhibits bone healing

Question 11

Aspirin Vs. other NSAIDs

Answer 11

Aspirin:
-10-20x cheaper than prescription NSAIDs
-5x cheaper than nonprescription NSAIDs

Others:
-less GI discomfort, but has some stomach irritation
-some are less toxic to liver and kidneys

Question 12

What is the only COX-2 selective drug still on the market?

Answer 12

Celebrex- most NSAIDs are nonselective, meaning they inhibit both COX-1 and COX-2 enzymes

Question 13

Why have most of the COX-2 selective drugs been taken off the market?

Answer 13

The cause an increase in upper respiratory infections, along with an increased risk of heart attack and stroke in those with cardiac risk factors

Question 14

What is Acetaminophen used for mostly?

Answer 14

Used to treat non-inflammatory conditions and used in early stages of OA or other non-inflammatory MSK conditions. Also used for fevers in children and teens
-especially used when the patient has a history of gastric damage =

Question 15

How does Acetaminophen work?

Answer 15

inhibits the COX enzyme- it is unknown why it doesn’t have anti-inflammatory or anti-coagulant effects like NSAIDS

Question 16

What is RA?

Answer 16

A chronic systemic disorder that causes destruction of the articular cartilage within joints- results in pain, stiffness, and inflammation of joints of the hands, feet, and knees

Question 17

What are the two goals of RA treatment?

Answer 17

1. Decrease joint inflammation
2. Decrease or stop the progression of the disease

Question 18

What are the three categories of drugs used for RA?

Answer 18

1. NSAIDs
2. Glucocorticoids
3. Disease-modifying antirheumatic drugs (DMARDs)

Question 19

Which drugs are used first to treat RA?

Answer 19

DMARDs are used first because they slow the progression of RA- NSAIDs are used for reducing inflammation and pain

Question 20

Why are NSAIDs typically used over Glucocorticoids?

Answer 20

Glucocorticoids reduce inflammation to a great extent, however large doses are required to have an effect which can result in serious side effects

Question 21

Why is Acetaminophen not recommended for treating RA?

Answer 21

It has no anti-inflammatory properties

Question 22

Should DMARDs and Glucocorticoids be taken together?

Answer 22

Yes. Since DMARDs take several weeks to become effective, using small doses of glucocorticoids in combination with DMARDs can help control pain and inflammation until DMARDs take effect

Question 23

When can glucocorticoids be used?

Answer 23

Can be used during acute-flare ups or exacerbations of RA- can be injected directly into the joint but only 2-3 injections per joint per year are allowed

Question 24

What is the Mechanism of Action of Glucocorticoids?

Answer 24

Binds to a receptor to form a glucocorticoid-receptor complex, this complex binds to genes that regulate the inflammatory process which inhibits the production of inflammatory substances and then the production of anti-inflammatory proteins occurs

Question 25

Side effects of Glucocorticoids

Answer 25

-osteoporosis -muscle wasting/weakness -HTN -aggravation of MD -glaucoma -cataracts -increased risk of infection

Question 26

Why are DMARDs so beneficial?

Answer 26

These can slow the disease progression of RA and promote remission before the joints become too damaged- they inhibit certain aspects of the immune response that is the cause of RA

Question 27

What are the the different DMARDs drugs?

Answer 27

-Antimalarials -Gold Compounds -Nonbiological DMARDs -Biological DMARDs (Tumor Necrosis Factor Inhibitors) -Other

Question 28

When are Antimalarials used?

Answer 28

They are not the first choice of DMARD of choice and are only used for those who cannot tolerate other DMARDs

Question 29

Why has the use of Gold Compounds decreases significantly?

Answer 29

There is a concern that gold therapy suppresses the immune system long term- only used for patients who don't respond to other DMARDs

Question 30

Which drug is a cancer treatment but also used to treat RA in children and adults?

Answer 30

Methotrexate- decreases synovitis, decreases bone erosion, and decreases the narrowing of the joint space

Question 31

Side effects of Methotrexate

Answer 31

-very toxic drug (low TI) -GI problems -pulmonary problems -hematological disorders -liver dysfunction -hair loss **primarily with long term use

Question 32

What is TNF-alpha?

Answer 32

A protein that is released from cells involved in inflammatory responses. This protein promotes joint erosion and inflammation in those with RA

Question 33

How do Tumor Necrosis Factor Inhibitors work?

Answer 33

Inhibits TNF-alpha which slows the progression of the destructive effects of RA- must be given as subcutaneous injection or by slow IV fusion

Question 34

When will physicians choose to prescribe other immunosuppressants for RA management?

Answer 34

When patients haven't responded to traditional DMARDs because these other drugs are more toxic

Question 35

What is considered the cornerstone drug for RA and what is it often combined with?

Answer 35

Methotrexate is the cornerstone and Tumor Necrosis Factor Inhibitors are usually combined with it- combining DMARDs may provide the best success for RA remission

Question 36

Beneficial Foods for RA Treatment

Answer 36

-food high in fish oil and omega-3 fatty acids: helpful in controlling inflammation -fruits and veggies: high in antioxidant properties -low meat and proteins: these foods can exacerbate symptoms -no smoking

Question 37

What causes OA?

Answer 37

An intrinsic defect in the remodeling of joint cartilage and underlying subchondral bone which causes progressive deterioration of articular cartilage- NOT an immune system response

Question 38

Treatment Goals for OA

Answer 38

-PT -weight loss -joint replacements in advanced stages **non-pharmacological interventions- joint inflammation is NOT a major focus

Question 39

What is the goal of drug therapy for OA?

Answer 39

Used to manage pain and maintain active lifestyle- focuses on acetaminophen and NSAIDS

Question 40

What is the first drug used for OA?

Answer 40

Acetaminophen

Question 41

Why are NSAIDs used for OA?

Answer 41

They are used to treat pain. Their anti-inflammatory properties can also help with mild synovitis that occurs with the joint destruction

Question 42

Which drugs have started to emerge that slow or reverse the pathological changes of OA?

Answer 42

DMOADs

Question 43

Which type of DMOAD uses hyaluronic acid to restore the lubricating properties of synovial fluid in arthritic joints?

Answer 43

Viscosupplementation- it is injected into the joint to restore viscosity which helps limit joint destruction progression in OA patients

Question 44

Viscosupplementation Timeline

Answer 44

-3-5 weekly injections can be given -there will be a decrease in pain within days -is beneficial for 6 months-1 year after a series of injections -delays the need for more aggressive treatment: joint replacement

Question 45

What are two key ingredients in dietary supplements are needed to produce synovial fluid and articular cartilage?

Answer 45

Glucosamine and Chondroitin Sulfate- may help to protect cartilage or reverse the joint deterioration in OA- types of DMOADs