Osteoarthritis

Question 1

Definition of OA

Answer 1

chronic, progressive disorder characterized by the loss of articular cartilage in primarily hands, knees, hips and spin

Question 2

Peak age onset of OA

Answer 2

50-60 years

Question 3

What is the MOA of OA

Answer 3

not understood
but joint trauma is a factor

Question 4

List the stages of progression of OA

Answer 4

articular cartilage changes
bone remodeling
synovial inflammation
soft tissue inflammation

Question 5

Risk factors that are modifiable for OA

Answer 5

obesity
joint trauma

Question 6

Risk factors non modifiable for OA

Answer 6

age
genetics
sex
joint misalignment /deformity

Question 7

List some major clinical features of OA (difference between RA and OA)

Answer 7

initial absence of inflammation or joint swelling
mono-articular at first
pain and stiffness with activity
no systemic symptoms

Question 8

Other general clinical features of OA

Answer 8

gradual onset
crepitus
tenderness
limited range of motion
bony swelling
joint deformity
instability

Question 9

List and describe the stages of pain for OA

Answer 9

stage 1 - predictable, sharp pain brought on by activity
stage 2 - pain becomes more constant; episodes of stiffness
stage 3 - constant dull/aching pain; chronic stiffness; episodes of intense exhausting pain

Question 10

Which joints are most commonly affected in OA?

Answer 10

Distal interphalangeal (DIP), proximal interphalangeal (PIP), joints of thumb
Cervical and lumbar spine
Hip, knee, metotarsophalangeal joint

Question 11

Describe the general diagnostic criteria

Answer 11

persistent usage related pain
age>45 years
little early morning stiffness; more evening stiffness

Question 12

Goals for OA

Answer 12

reduce pain
maintain or improve joint mobility
limit functional disability
improve self-management

Question 13

List the 4 pillars of tx of OA

Answer 13

patient education
rehabilitation
medications
referral (surgical/non surgical)

Question 14

What is the important part of patient education of lifestyle changes for OA?

Answer 14

emphasize importance of weight control

Question 15

List some of the aspects of rehabilitation for OA

Answer 15

exercise
physiotherapy
relaxation, mind/body
other - acupuncture?
environmental changes/aids

Question 16

(T/F)
Non pharm interventions remain the most effective interventions for OA

Answer 16

True - often underutilized interventions for OA

Question 17

List some non surgical referrals for OA

Answer 17

dietician
physiotherapy or OT
physician - pain medication
Rheum or Internal Medicine Specialist

Question 18

Types of Surgery to help with OA

Answer 18

Osteotomy (removal of bony tissue)

Debridement (orthoscopic surgery)

Joint Replacement (arthroplasty)

Question 19

List some of the medication that can be used for OA

Answer 19

Acetaminophen
Topical NSAIDs
Other topical (capsaicin, a535)
Oral NSAIDs
Opioids (traditional and tramadol)
Duloxetine
Injectable joint replacement fluid
Injectable glucocorticoids

Question 20

When should capsaicin in OA

Answer 20

knee
Against in hand

Question 20

When should Topical NSAIDs in OA

Answer 20

hand, knee

Question 20

When should oral NSAIDs in OA

Answer 20

hand, knee, hips

Question 20

When should acetaminophen in OA

Answer 20

hand, knee, hip

Question 20

When should duloxetine in OA

Answer 20

hand, knee, hip

Question 20

When should tramadol in OA

Answer 20

hands, knee, hip

Question 20

When should hyaluronic acid in OA

Answer 20

against in hands, knee, hip

Question 20

When should traditional opioids in OA

Answer 20

against in all hands, knee, hip

Question 21

When should IA corticosteroids in OA

Answer 21

hands, knee, hips

Question 21

When should glucosamine in OA

Answer 21

against in hand, knee, hip

Question 22

When should chondroitin in OA

Answer 22

Undecided for hands against - knee and hips

Question 23

What is the limit per year on injectable corticosteroids and why?

Answer 23

The cartilage degradation – why it is limited to 3-4 injections in one joint per year

Question 24

How long does injectable corticosteroids typically last?

Answer 24

4-8 weeks but some get longer

Question 25

What is hyalyronic acid?

Answer 25

injectable joint fluid replacement

Question 26

Dosing for OA for duloxetine

Answer 26

30mg OD x 1-2 wks, increase up to 60mg od (max 120mg od)

Question 26

Adverse effects for hyaluronic acid

Answer 26

arthralgia, injection site pain/reaction, post inj flare

Question 27

Common dose for glucosamine

Answer 27

500 mg tid or 1500 mg Once daily need to use for 3 months before results

Question 28

Concerns about glucosamine

Answer 28

good safety profile ??incre INR, bleeding risk do not have a great studies

Question 29

What to know about chondroitin

Answer 29

less data than glucosamine dose - 1200mg/d concerns - good safety profile, ?incr INR, bleeding risk

Question 30

Dose for tramadol

Answer 30

1-2 tabs q4-6h prn (max 8 tablets per day)

Question 31

When is traditional opioids used in OA?

Answer 31

only for select patients / last time therapy

Question 32

List some key takeaways for OA

Answer 32

Don’ forget about non-therapeutic measures (eg. Benefits of exercise, weight loss) OA favours a “go slow” approach Ensure adequate trial of an option before modifying Generally add-on therapy rather than replacement Acetaminophen – not as effective as previously thought For NSAIDs, utilize low doses as much as possible Topicals are an important option Strong opioids are usually inappropriate Consider each patient. Think of comorbidities, risks, benefits and preferences