OA

Question 1

joints primarily affected

Answer 1

hands, hips, knees

Question 2

primary OA

Answer 2

idiopathic

Question 3

secondary OA

Answer 3

due to somethign

Question 4

protective features of the joint

Answer 4

synovial fluid reduces friction
ligaments and tendons allows for the right tension
bone - shock absorbing
cartilage - thin coating at two opposing ends of bones

Question 5

general pathophys

Answer 5

complex interaction of may extra and intracellular molecules
bone turnover favors cartilage destruction

Question 6

risk factors for osteo

Answer 6

ethnicity 
age
gender (men at first then women)
bone density 
nutritional 
joint injury 
obesity 
occupation 
joint biomechanics
muscle weakness

Question 7

clinical diagnosis

Answer 7

> 45
activity related joint pain
morning stiffness <30min
lab tests only to rule out other causes

Question 8

symptoms **

Answer 8

stiffnes in morning or after periods of inactivity <30min
localized to affected joint
pain worse with activity or prolonged use

Question 9

signs ***

Answer 9

often unilateral
joints not tender or inflamed
joint instability
no systemic symptoms

Question 10

cause of pain

Answer 10

not due to destruction of catilage
from activation of nociceptive nerve endings within the joint by mechanical and chemical irritants
may be due to distension of the synovial capsule

Question 11

what do we see in xrays

Answer 11

narrowing of joint space
osteophytes
bone cysts

Question 12

when do we do xrays

Answer 12

not needed for intial usual presentation of OA or follow up

symptoms dont correlate with image abnormalities

Question 13

nodes in OA

Answer 13

heberden

bouchard

Question 14

reasons for further evaluation in patient complaining of new onset joint pain

Answer 14

duration > 1week 
recent significant trauma 
fever, infection, rash
injury 
muscle weakness
burning, numbness, tingling
inflammation or stiffness >1hr

Question 15

goals of therapy***

Answer 15

relieve or eliminate pain
improve/restore joint function adn mobility
improve muscel strength to protect the structures
prevent and reduce damage to the joint structures
max quality of life
educate the patient to promote adherence

Question 16

algorithm for treatment

Answer 16

1. non pharm, topical analgesics
2. acetaminophen
3. asses GI and CV risks and choose a nsaid

Question 17

low GI and CV risk

Answer 17

low dose non selective nsaid

Question 18

low GI and high CV

Answer 18

naproxen + gastroprotection

Question 19

high GI high CV

Answer 19

naproxen + gastroprotection +
low dose celecoxib ?
avoid

Question 20

high GI low CV

Answer 20

low dose NSAID + gsatroprotection or low dose celecoxib

Question 21

high GI and CV factors, previous ulcers, use of oral corticosteroids or anticoagulants (including low dose ASA)

Answer 21

low dose celecoxib + gastroprotection

Question 22

options for hand OA

Answer 22

topical capsaicin or nsaids

oral nsaids

Question 23

options for knee OA

Answer 23

acetaminophen
topical and oral nsaids
intraarticular corticosteroids injections
not topical capsaicin

Question 24

options for hip OA

Answer 24

acetaminophen first line
intrarticular corticosteroid injections
oral nsaid
not topical capsaicin

Question 25

non pharms

Answer 25

``` strength training and aerobic exercise weight loss joint protection supportive footwear assistive devices social support heat and cold therapy massage surgery ```

Question 26

acetaminophen dosing

Answer 26

325-100mg every 4-6 hrs for 2 weeks | max 4g/day

Question 27

acetaminophen role

Answer 27

first line

Question 28

acetaminophen efficacy

Answer 28

same as nsaids in mild non inflammatory | less effective in advanced

Question 29

safety of acetaminophen

Answer 29

max 3.2g/day in elderly avoid in >3 drinks per day warfarin hepatotoxicity

Question 30

capsaicin dosin

Answer 30

apply tid-qid for 3-4 weeks

Question 31

capsaicin role

Answer 31

first line in hand

Question 32

capsaicin onset

Answer 32

2 weeks to take effect

Question 33

safety of capsaicin

Answer 33

tingling, burning, redness

Question 34

topical diclofenac role

Answer 34

first line in hand or knee

Question 35

safety of topical diclofenac

Answer 35

minimal systemci safety concerns

Question 36

NSAID role

Answer 36

alternative for hand if cant toleracte skin reactions or inadequate relief in knee and hip if fail or contraindication to acetaminophen

Question 37

safety of nsaids

Answer 37

nausea, abd pain, diarrhea | ulcer, GI bleed, kidney disease, hepatitis

Question 38

what is considered high CV risk

Answer 38

on lose dose ASA | high 10yr CV risk

Question 39

methylprednisone dosing

Answer 39

10mg per joint, 20-80 for large | max 3 injection/joint/year

Question 40

IA steroids role

Answer 40

alternative first line for knee and hip when pain control with acteaminophen or nsaids suboptimal

Question 41

efficacy of IA

Answer 41

superior to placebo in alleviating pain but relatively short duration (4-6 weeks)

Question 42

safety og IA steroids

Answer 42

inexpensive, safe, effective | hyperglycemia, edema, increase BP, flushing

Question 43

sodium hyaluronate dosing

Answer 43

injection once or weekly for 3-5week

Question 44

role of IA hyluronic aicds

Answer 44

not recommended | limited efficacy and serious events

Question 45

IA hyluronic acid safety

Answer 45

increased pain, joint swelling, stiffness | pseudogout

Question 46

duloxetine dose

Answer 46

60mg daily

Question 47

duloxetine role

Answer 47

adjunctive in partial response to first line analgesics | second line in patients with neuropathic pain as well

Question 48

duloxetine efficacy

Answer 48

as an add on shown effiacy | reduction of pain occurs in 4 weeks

Question 49

safety of duloxetine

Answer 49

nausea, vomit, constipation | CI in liver disease and severe renal impairment

Question 50

tramadol dose

Answer 50

25mg AM titrate 25mg to reach 100tid

Question 51

tramadol role

Answer 51

alternative first line in knee/hip who failed everything else can add on to acet or nsaid

Question 52

tramadol efficacy

Answer 52

mod improvement as add on | reduction in pain occurs in 4 weeks

Question 53

tramadol safety

Answer 53

nausea, vomiting, dizzy, constipation, headache | taper

Question 54

cox 2 inhibitors gastroprotective effects are negated by

Answer 54

ASA

Question 55

glucosamine chondroitin efficacy

Answer 55

not shown to improve pain control and function | studies that showed any benefit were short duration

Question 56

risk factors for UGI event

Answer 56

``` >65yo use of anticoagulants use of steroids history of PUD high dose NSAID presence of hpylori ```

Question 57

bottom line for corticosteroids shots

Answer 57

reduce pain at 6 weeks but then less and less | long term pain relief uncertain but serious events are very rare

Question 58

adequate trial of duloxetine

Answer 58

if min response at 6 weeks probably wont get a beter one

Question 59

monitoring

Answer 59

``` decrease in pain daily pain relief daily hepatotoxicity baseline and annual blood in vomit or stool BP iwithin 1 week of nsaid therapy renal function - edema, scr ```