Week 2 Flashcards
(154 cards)
1
Q
What are the characteristics of nociceptive pain?
A
• Noxious peripheral stimulus affects a structure
- Mechanical, chemical irritant, heat, cold
• Somatic versus visceral
- Somatic: injury to bone, skin, etc.
- Visceral: compression/ distension of internal organs (pancreatitis, cancer pain, etc)
2
Q
What are the characteristics of neuropathic pain?
A
- More often chronic versus acute
* Damage to the peripheral or central nervous system
3
Q
What are the ways to assess pain intensity?
A
- Word scale (none to excruciating)
- Visual Analogue Scale (0 – no pain; 10 = worst possible)
- Wong-Baker FACES Pain Scale
4
Q
What are the descriptive terms used for pain?
A
“Throbbing, aching, cramping” – nociceptive pain
• “Burning, tingling, stabbing, shocking” – neuropathic pain
5
Q
What is Acetaminophen (Tylenol) used for?
A
- Used in mild/moderate pain when used alone
- Used for moderate/severe pain when paired with opioids. Ex: oxycodone and acetaminophen (Percocet®)
- Commonly used to reduce fever
6
Q
What are the characteristics of Acetaminophen (Tylenol)?
A
• Mild adverse effect profile
• Liver toxicity at high doses
- Commonly seen as a tool for suicide attempts
• Available for oral and intravenous administration
7
Q
What are the types of NSAIDS (Non-steroidal, anti-inflammatory drugs)?
A
Aspirin, Cox-1, Cox-2 inhibitors
8
Q
What do prostaglandins lead to?
A
Lead to inflammation and pain when injury occurs
9
Q
What is the function of a cyclooxygenases(COX)?
A
Convert arachidonic acid to
prostaglandins
10
Q
What is the function of an NSAID?
A
Inhibit COX enzymes and block pro-inflammatory prostaglandins
11
Q
What does Cox-1 do?
A
Helps to protect the stomach lining via prostaglandins
12
Q
What does a more COX-2 selective drugs lead to?
A
Leads to less stomach upset and bleeding
13
Q
What does a more COX-2 selective drugs do?
A
Shifts the balance of platelet activity to favor increased clotting by inhibiting prostacyclin (promotes vasodilation and prevents platelet occlusion in carotid arteries), while continuing to allow thromboxane (promotes platelet aggregation) production.
14
Q
What kind of risk is associated with a COX-2 selective drug?
A
Cardiac Risk
15
Q
What are the actions of a NSAID?
A
- Analgesic
- Anti-inflammatory
- Anti-pyretic
- Anticoagulant
16
Q
What are the side effects of a NSAID?
A
- Drowsiness
- Dizziness
- Blurred vision
- Bleeding
- Anemia
- Dermatologic rash
- Renal toxicity
- Hyperkalemia
- Cardiovascular Events: e.g. heart attack and/or stroke
- Gastrointestinal Events: e.g. GI irritation, inflammation, ulceration bleeding
17
Q
What are the risk factors for increased risk of GI
bleed with the use of NSAIDs?
A
- Advanced Age
- Multiple NSAIDS
- High Dose of NSAIDS
- History of Ulcers
- Alcoholism
- Use of Other Agents (anticoags, steroids, etc.)
18
Q
What is an opiod?
A
Endogenous and exogenous substances that act on opioid receptors
19
Q
What are the 4 steps to nociceptive pain?
A
- Stimulation
- Transmission
- Perception
- Modulation
20
Q
What is the feature of the 1st step to nociceptive pain?
A
Stimulate the nociceptors
21
Q
What is the feature of the 2nd step to nociceptive pain?
A
- Afferent fibers transmit signals to the “dorsal horn” of the spinal cord
- Signal then travels to the cortex via the thalamus
22
Q
What is the feature of the 3rd step to nociceptive pain?
A
- Information reaches the somatosensory cortex
* Pain is “felt.” Pain perception
23
Q
What is the feature of the 4th step to nociceptive pain?
A
Pain can be tolerated or reduced by endogenous opiates
24
Q
What type of receptor do endogenous opioid: endorphins have?
A
Mu (µ)
25
What type of receptor do endogenous opioid: enkephalins have?
Delta (δ)
26
What type of receptor do endogenous opioid: dynorphins have?
Kappa (ĸ)
27
What are endorphins used for?
* Acute and chronic pain
* Facilitates reward and abuse
* Sedation, euphoria, respiratory depression, miosis, vomiting, constipation
28
What are enkephalins used for?
* Moderate in chronic pain
* Facilitates reward and abuse
* Sedation, antidepressant, neuroprotection
29
What are dynorphins used for?
* Hyperalgesia
* Inhibits reward and abuse
* Sedation
* Dysphoria
30
Excessive opioid exposure may lead to ___ or ____
Excessive opioid exposure may lead to *hyperalgesia or allodynia*
31
What is hyperalgesia?
* Paradoxical increase in pain sensitivity
| * Increased painful response to noxious stimulation
32
What is allodynia?
Painful response to non-painful stimuli
33
What are the characteristics of opioid induced hyperalgesia?
• Increasing pain with increased opioid dose
• N-methyl-D-aspartate (NMDA) receptor antagonists may help
- Ketamine, dextromethorphan
34
What are some opioid receptor antagonists?
* Naloxone
* Buprenorphine and Naloxone
* Naltrexone
35
What is naloxone used for?
* Used for opioid overdose
| * Mu receptor antagonist
36
What is buprenorphine and naloxone used for?
* Used for opioid dependence
| * Buprenorphine agonizes mu and kappa receptors
37
What is naltrexone used for?
* Used for the treatment of alcohol and opioid dependence
* Mu receptor antagonist
* Blocks euphoric feelings associated with opioid abuse
38
What are the different forms of opioid administration?
* Oral
* Transdermal
* Transmucosal
* Rectal
* Intrathecal
* Intravenous, intramuscular, subcutaneous
* Patient Controlled Analgesia (PCA)
39
What are the characteristics of the oral opioid administration?
(immediate release and extended release)
• Pain management general rule
- 1 tab daily or BID extended release formulations to PREVENT pain
- Use the immediate release as needed (PRN) for breakthrough pain
- If patient getting too many breakthrough doses, adjust the
extended release dose
- IT IS EASIER TO PREVENT PAIN THAN TREAT IT
40
What are the characteristics of the transdermal opioid administration?
Extended pain control, swallowing issues, cognitive impairment
41
What are the characteristics of the transmucosal opioid administration?
* Fentanyl “lollipop
| * Absorbed through oral mucosa
42
What are the characteristics of the rectal opioid administration?
* Suppository
| * Absorbs through rectum
43
What are the characteristics of the patient controlled analgesia (PCA) opioid administration?
* Pump that delivers medication
* Programmed by M.D.
* Patient can self administer
* Bolus dose: Patient presses a button to self administer
44
What are the safety measures used for a PCA?
• Lockout interval stops patient from self administering too often
• Dose limit minimizes risk of overdose
• Loading dose
- To quickly increase levels of medication for acute pain
• Basal Rate
- Continuous rate of infusion
45
What are the adverse effects of opioids?
```
• Drowsiness
• Dysphoria
• Cognitive impairment
• Delirium
• Nausea, vomiting
• Respiratory depression
(high doses)
• Itching
• Urinary retention
• Postural hypotension
• Sweating
```
46
What are the impact of opioids on rehab?
• Scheduling/Timing
• PCA Guidance – understand the rules!
• Mange sedation and constipation/GI upset
• Be aware of respiratory depression effect
• Be alert for withdrawal symptoms and symptoms of
dependency
• Assist in coping with withdrawal (PT pain management)
47
What are the symptoms of an opioid withdrawal?
* Aches
* Runny nose/Sneezing
* Diarrhea
* Shivering
* Fever
* Stomach Cramps
* Insomnia
* Sweating
* Irritability
* Tachycardia
* Low appetite
* Uncontrollable Yawning
* Nausea/Vomiting
* Weakness/Fatigue
48
What is tolerance as it relates to opioids?
Need more medication for same effect
49
What is tolerance as it relates to opioids?
Need more medication for same effect
50
What is physical dependence as it relates to opioids?
Physical symptoms when medication/drug is removed
51
What is abuse/psychological dependence as it relates to opioids?
Behaviors described as “loss of control” and preoccupation with the substance being abused
52
___ is typically related to afferent receptors activating pain response that is delivered to and can be modulated by the CNS.
*Acute pain* is typically related to afferent receptors
activating pain response that is delivered to and can be
modulated by the CNS.
53
___ are common drugs that can have antiinflammatory, analgesic, antipyretic & anticoagulant
properties.
*NSAIDs* are common drugs that can have antiinflammatory, analgesic, antipyretic & anticoagulant properties.
54
___ are first-line drugs for mild-moderate pain, but can have GI & other side effects
*NSAIDs* are first-line drugs for mild-moderate pain, but can have GI & other side effects
55
____, used for higher levels of pain, act centrally and can become addictive.
*Opioids pain meds*, used for higher levels of pain, act
| centrally and can become addictive.
56
____ can relieve pain/fever, but does not have anti-inflammatory effect
*Acetaminophen* can relieve pain/fever, but does not have
| anti-inflammatory effect
57
What is one of the big problems with the prolonged use of opioids?
Constipation
58
What are the medicines that are often used to mitigate constipation as a side effect of opioids?
- Relistor (methylnaltrexone): Mu-opioid receptor antagonist
- Amitiza (lubiprostone): Increased intestinal fluid
secretion and mobility (bypasses
antisecretory action of opiates)
- Movantic (Naloxegol): Mu-opioid receptor antagonist
59
What is chronic pain defined by?
* Duration: beyond several months, longer than “normal” from an injury
* Appropriateness – should it hurt?: (Hyperalgesia and Allodynia)
* May also hear “persistent pain”
60
What is hyperalgesia?
Increased pain beyond a normal response to stimuli
61
What is allodynia?
Pain from a stimuli that does not normally cause pain
62
What are the characteristics of chronic pain?
* NOT considered continuous acute pain
* DISTINCT
* Progressive
* Disconnect form usual nociceptive pain that persists while the stimuli is causing pain
63
Prolonged nociceptive input can lead to ____
Prolonged nociceptive input can lead to *chronic pain secondary to central hypersensitization*
64
What are things that may occur subsequent to tissue damage that are possible explanations for chronic pain?
* Peripheral sensitization
* Central sensitization
* Ectopic excitability
* Disinhibition
* Structural reorganization
65
Peripheral sensitization leads to ___
Peripheral sensitization leads to *chemicals that increase sensitivity of nerve fibers*
66
What is central sensitization?
Amplified response to low stimuli
67
What is ectopic excitability?
Pain from injured fibers may generate pain signals with
| minimal or stimulation
68
What is disinhibition?
When an injury may lead to a reduction of pain inhibitory cells
69
What is structural reorganization?
“Non-pain fibers” start to trigger pain
70
____ is the most common cause of long term disability and is commonly seen with co-morbidities
*Chronic pain* is the most common cause of long term disability and is commonly seen with co-morbidities
71
What are the impact of chronic pain on daily life?
* Lost work days
* Disruption in personal relationships
* Anxiety
* Depression
* Impaired sleep
* Substance use disorders
72
What are the different types of chronic pain?
```
• Neuropathic pain
• Fibromyalgia
• Phantom pain
• Other
- Arthritis, unknown cause, subsequent to injury, etc.
```
73
What is the pathogenesis of neuropathic pain?
* Damage to the sensory nervous system
| * Compressed, severed nerve
74
What are some diagnoses that may lead to neuropathic pain?
* Diabetes, autoimmune, infections, post stroke
| * Post herpetic neuralgia “shingles”s pain
75
What is phantom pain?
Pain in an ABSENT TISSUE
76
Most people that have phantom pain are ____
Patients after amputation
77
Phantom pain can also occur in aplastic phantoms. What is aplastic phantom?
Patients born without limbs experiencing pain in absent areas
78
What are some of the proposed theories for the pathophysiology of phantom pain?
• Previously thought to be psychogenic
• Evidence for changes in the peripheral and central nervous
system after amputation
79
How do patients with phantom pain describe it?
Patients describe “burning, gnawing, pressure or aching” in
| the non-existent area
80
How long does phantom pain last?
* Episodic: minutes to hours
| * Continuous
81
What are the possible mechanisms of phantom pain?
• Neuromas in afferent pathways at site of lost limb
• Consistent stimuli in efferent pathways
• Hyperexcitability in spinal cord leading to somatosensory
cortical remapping
82
What is fibromyalgia?
Widespread musculoskeletal pain
83
What is the pathogenesis of?
* Central sensitization
* Low levels of heat, pressure are painful
* Low levels of endogenous opioids
* Changes in opioid receptors, peripherally an centrally
* Increased substance P (related to pain transmission)
* MRIs reveal increased activation in pain-sensitive brain areas
84
What are the tender points of fibromyalgia?
* Under low SCM
* Near second costochondral junction
* Distal area of the lateral epicondyle
* Greater trochanter
* Medial fat pad of knee
* Insertion of suboccipital muscle
* Mid upper trap
* Origin of the supraspinatus muscle
* Upper quadrant of the buttock
85
What are the characteristics fibromyalgia?
* Commonly seen with chronic fatigue, anxiety, depression, cognitive issues, headache, paresthesias
* More common in women
86
What are the non- pharm treatment of fibromyalgia?
Exercise and PT
87
Chronic pain is as a result of ____
Prolonged nociceptive input
• Hypersensitization
• Spontaneous pain
• Amplified pain
88
____ are helpful for many chronic pain conditions
*Opioids* are helpful for many chronic pain conditions
89
What are the opioid limitations with chronic pain?
• Decreased efficacy over time (tolerance)
• Increased dose to maintain same effect
• Feelings of euphoria – “controlled substances” C-II
• ~30% of patients continue to experience pain reduction
past 18 months
90
What is the cycle of pain and addiction as it relates to opioids and chronic pain?
• Positive reinforcement
- Linked to feelings of reward, euphoria
• Negative reinforcement
- Pain reduction
• Doses increase as tolerance develops to pain relief
• Prevalence of opioid use disorders in chronic pain
- General opioid use in chronic pain 20-24%
- Opioid use disorders in chronic pain 36%
91
What are the methods of the management of chronic pain in patients with substance use disorders (SUDs)?
• Non-opioid analgesics based on pain physiology
- NSAIDS, TCAs, SNRIs, AEDs
• Opioids can be continued ONLY if patient is in a SUD
treatment program
92
What are the non-pharmacologic pain treatments for chronic pain?
• Therapeutic exercise
- Increase strength, flexibility, balance
- Reduce anxiety and depression
• Cognitive-behavioral therapy
- Learn how to deal with negative situations and thoughts in a more positive way
• Complementary medicine
- Chiropractic, massage, acupuncture
93
What is osteoporosis?
Systemic skeletal disorder characterized by compromised bone strength
94
What does osteoporosis do?
Predisposes patients to increased risk for fractures
95
In what population is osteoporosis more common?
Most common in post-menopausal women
96
What is the architecture of spongy or trabecular bone?
* 20% of skeleton
* Found in interior of bones
* Trabeculae form lattice-like structure
* Large surface area, metabolically active
97
What is the architecture of compact or cortical bone?
* 80% of skeleton
* Outer protective shell
* Found peripherally
98
How does bone remodeling occur?
Occurs continually based on signaling from damaged cells
99
What is osteoblasts?
Bone-building cells that secrete collagen and other bone matrix proteins, and promotes bone mineralization
100
What is osteoclasts?
Bone-resorbing cells (old and worn out bone) that forms pits (lacuna).
101
When do humans achieve maximum bone density?
* 90% by age 18
| * Completion by early 30’s
102
What are the factors that impact peak bone mineral density (BMD)?
* Exercise (weight bearing) – helps to keep bones strong
* Lifestyle – smoking, drinking alcohol
* Disease states – kidney disease (regulates mineral, ion homeostasis), hyperparathyroidism (causes bone resorption and removes Ca2+ from skeletal stores)
* Medications – cancer meds, seizure meds, steroids (prednisone)
* Nutrition – vitamin D and calcium
103
When does the bone mass of a person begin to decrease?
In the 4th decade of life
104
At what rate does the bone mass of a person decrease?
* 0.5% per year
| * Men = women
105
When does perimenopause occur?
5-7 years post-menopause
106
What occurs during perimenopause?
Loss increases to 3-5 % per year with the drop in estrogen
107
What does bone densitometry do?
Measures bone absorption of radiation or sound waves
108
How can bone densitometry be measured?
Can be measured peripherally or centrally
• Centrally – hip and spine, used for diagnosis and serial monitoring
• Peripherally – heel, finger, wrist, forearm, used for screening
109
What are the characteristics of the T-score method of measuring bone mass?
* Measures bone mineral density
* Compares the score to a young-adult reference population
* 2.5 below the reference population defines osteoporosis
* 1-2.5 defines osteopenia: low bone mass
110
What are the characteristics of the Z-score method of measuring bone mass?
• Compares the bone mineral density to an age-matched
population
• Less than 2 below the age-matched screening
- Check for other causes (diseases, medications, etc.)
111
What are the characteristics of a person's propensity to fall?
• In the elderly ~ 6% of falls lead to fractures
• A majority of fractures are due to falls
• Elderly fall more often due to:
- Decreased muscle strength and agility
- Increased medication use and disease states that impair cognition and balance
• Elderly tend to fall to their side = hip fractures
112
What are the options for the management of osteoporosis?
```
Lifestyle modifications
Calcium/Vitamin D
FDA approved Drug therapies
• Bisphosphonates
• Raloxifene (Evista®)
• Hormone replacement therapy (HRT)
• Calcitonin
```
113
What are the types of lifestyle modifications that can be used to manage osteoporosis?
• Exercise
- Weight-bearing exercise (jogging, walking, stair climbing, tennis)
- Resistance exercise (free weights or weight machines)
• Limit alcohol (< 2 drinks per day)
• Smoking cessation
• Fall precautions (in the home)
• Medications
114
What are the parameters of the calcium/vitamin D intake that can be used to manage osteoporosis?
Calcium
• Diet: dairy, green vegetables, nuts, etc.
• Per day: 1200 mg (diet and supplement)
Vitamin D – increases the absorption of calcium
• Diet: fortified milk, fish, cereals
• Per day: 1000 international units (IU)
• Sun?
- > 70 years the skin does not convert vitamin D as well as in
younger patients
- Light skin - 15 minutes ~ 10,000-15,000 units
- Darker skin – longer time
115
What are the functions of bisphosphonates as a means of managing osteoporosis?
* Stops osteoclast activity, inhibits bone resorption
* Considered 1st line therapy
* May be used for prevention and treatment
116
What are the types of bisphosphonates used as a means of managing osteoporosis?
* Etidronate (Didronel®)
* Pamidronate (Aredia®)
* Alendronate (Fosamax®)
* Risedronate (Actonel®)
* Zolendronate (Zometa®)
* Ibandronate (Boniva®)
117
What are the characteristics of the administration of bisphosphonates?
* Take upon arising in the morning with a full 8 oz glass of water
* Take on an empty stomach (do not eat, drink or take any other medications for at least 30 minutes after taking)
* Do not lie down for at least 30 minutes after taking
118
What are the side effects of bisphosphonates?
```
• GI side effects
- Dysphagia
- Esophageal ulceration/irritation
- Abdominal pain, Nausea
- Dyspepsia
• Avoid in renal dysfunction
```
119
What is raloxifene (Evista®)?
2nd line for patients who cannot tolerate bisphosphonates
120
What are the characteristics of raloxifene (Evista®)?
Selective Estrogen Receptor Modulator (SERM)
• Acts similar to estrogen
• Can be used to reduce risk of breast cancer
• Preventing bone loss, decreases bone resorption
121
What are the functions of raloxifene (Evista®)?
* Used for prevention and treatment
* Decreases vertebral fractures (~30%)
* No decrease in hip fractures
* Increases risk of DVT/PE 3 fold
122
What are the other side effects of raloxifene (Evista®)?
Hot flashes, flu like symptoms
123
What are the characteristics of parathyroid hormone replacement therapy?
• Not considered first line
• Recommended in patients who continue to fracture after one year of bisphosphonate therapy
• Helps modulate calcium and phosphate
• Intermittent use can stimulate bone formation and reduce
fracture risk – short term, max of 24 months
• May be more effective when administered with estrogen
therapy
124
What are the characteristics of Calcitonin Nasal Spray
| (Miacalcin®) used to manage osteoporosis?
* Derived from salmon
* Approved only for treatment in women more than 5 years post menopause
* Considered 3rd line therapy
* May offer more of an analgesic property in painful vertebral fractures
* Decreases bone resorption
* Decreases vertebral fractures (33-36%)
* Sprayed in alternating nostrils daily
125
What is osteoarthritis?
Long term degenerative joint disease, which results in cartilage damage by physical forces and/or or over use
126
What are the characteristics of osteoarthritis?
* > 40 years old
* Pain is worsened by activity, relieved by rest
* Patient’s present with asymmetric joint pain, stiffness
127
What are the common joints affected by osteoarthritis?
Fingers, knee, hip, spine
128
What are the uncommon joints affected by osteoarthritis?
Shoulder, elbow, wrist
129
What are the treatment options for osteoarthritis?
• NonPharm: Exercise programs, weight loss, braces, taping, heat, cold
• Pharm: PAIN Control. Tylenol, NSAIDs, intraarticular steroids
(glucocorticoids)
• No cure, increase quality of life and minimize pain
130
What are the characteristics of rheumatoid arthritis?
* Most common autoimmune, systemic inflammatory disease
* > 60% of cases occur in women between the ages of 15 – 45
* Considered a chronic disorder
131
What is the pathophysiology of rheumatoid arthritis?
• Chronic inflammation and
proliferation of synovial tissue lining the joint space
• The immune system fails to
differentiate between self and non-self and attacks the synovium and connective tissues
• The inflamed, proliferating synovium develops into a pannus which can invade the cartilage and bone surface
leading to erosions and joint
destruction
• Can also lead to extra-articular involvement
132
What is the clinical presentation of rheumatoid arthritis?
* Onset is slow, over weeks to months (may wax and wane)
* Morning stiffness in and around the joints lasting at least 1 hour
* Fatigue, weakness, low-grade fever, loss of appetite
* Symmetrical joint pain, stiffness, myalgia, joint swelling or deformity
* More common in hands and wrists
* Less common in the elbows, knees, feet, ankles, cervical spine, and temporomandibular joint
133
What are characteristics of nodules extra-articular involvement that are common in RA?
Asymptomatic; bumpy, scar-tissue regions primarily located in elbows, forearm, and hands
134
What are characteristics of vasculitis extra-articular involvement that are common in RA?
Invasion of vessel wall by inflammatory cells may produce infarction of distal tissue in fingers and toes
135
What are characteristics of pulmonary extra-articular involvement that are common in RA?
Pulmonary fibrosis; nodules in lung tissue may develop and appear to be neoplasm on radiography
136
What are characteristics of ocular extra-articular involvement that are common in RA?
Inflammation of the sclera, cornea; atrophy of the lacrimal glands and reduced tear productions
137
What are characteristics of cardiac extra-articular involvement that are common in RA?
Pericarditis, pericardial effusion; rarely cardiac tamponade (inflammation of heart lining)
138
What is Felty’s syndrome?
RA with splenomegaly and neutropenia, thrombocytopenia
139
What are the goals of medication therapy used for the management of RA?
```
• Goal is to induce remission (rarely happens)
• Other goals:
- Control disease activity
- Alleviate pain
- Maximize quality of life (QOL)
- Slow rate of disease progression
- Maintain ADL’s and work
```
140
What are the types of medication therapy used for the management of RA?
* NSAID’s
* Oral or local steroids
* DMARDs (Disease Modifying Anti-Rheumatic Drugs)
* Combinations
* Joint replacement
141
What are the characteristics of the NSAIDs used to manage RA?
* Scheduled regular dosing at anti-inflammatory doses (moderate to high doses)
* Will not prevent progression, but will help with the symptoms
142
What are the Commonly used NSAID’s to treat RA?
* Ibuprofen 600-800 mg PO TID
* Naproxen 500-750 mg PO BID
* Diclofenac 75 mg PO TID
* Salsalate 750-1500 mg PO BID
* Etodolac 400-600 mg PO BID
* Nabumetone 750-1000 PO BID
143
What is the goal of DMARDs as a way to manage RA?
To induce remission
144
What are the characteristics of DMARDs?
* May take months to work
* Biologic DMARDs generally work faster
* Efficacy may not last long-term
* Will modify disease state, AND help relieve symptoms
* Start within 3 months in ANY patient with an established diagnosis
* Sooner the better!
145
What are biologic DMARDs?
Medications produced by living systems
| • e.g. Vaccines, interferons, monoclonal antibodies
146
What are the characteristics of corticosteroids as a means of treating RA?
* Low-dose oral therapy (prednisone <10 mg daily)
* Maintenance therapy usually reserved for cases when disease is active despite adequate NSAID treatment after a trial of DMARD therapy
* May be used adjunctively with a DMARD
* Regular steroid use can lead to hypertension, glucose abnormalities, irritability, bruising, fluid retention, peptic ulcers, insomnia, etc., etc., etc.
* Oral burst therapy can be used for acute flare-ups
* Local injections which may recover lost joint motion and provides only local beneficial effects, no systemic benefits
147
Bone mineral loss ____ with age and some disease processes
Bone mineral loss **increases** with age and some disease
| processes
148
Parathyroid hormone is crucial in maintaining _____ and in regulating _____
Parathyroid hormone is crucial in maintaining **blood Ca+ levels**
and in regulating **bone formation/resorption.**
149
Parathyroid hormone interacts with ____ and ___ to control
Parathyroid hormone interacts with **Vitamin D and calcitonin** to control
150
Bisphosphonates blocks ____ and normalize bone turnover in osteoporosis; calcitonin also used
Bisphosphonates blocks **excessive bone resorption** and normalize bone turnover in osteoporosis; calcitonin also used
151
Arthritis, especially Rheumatoid type, can result in _____ with resulting pain & loss of function
Arthritis, especially Rheumatoid type, can result in **severe joint
damage** with resulting pain & loss of function
152
RA can be treated with ___, ___, and various ___.
RA can be treated with **NSAIDS, glucocorticoids, and various DMARDs.**
153
Glucocorticoids can ____, but long term use is limited due to toxic effects.
Glucocorticoids can **decrease joint inflammation,** but long term use is limited due to toxic effects.
154
Osteoarthritis typically can be managed with ____ and ___, but viscosupplementation may be used
Osteoarthritis typically can be managed with **NSAIDs and
| acetaminophen,** but viscosupplementation may be used
