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pharmacotherapy 4270 > 3. Osteoarthritis MT1 > Flashcards

3. Osteoarthritis MT1 Flashcards

1
Q

is osteoarthritis an inflammatory or noninflammatory disorder

A

noninflammatory

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2
Q

osteoarthritis is a disease of the _____ joints

A

synovial

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3
Q

true/false: osteoarthritis is due to daily “wear and tear” - due to excessive & repetitive force on the cartilage joints

A

partially true - it is a systemic disorder due to an imbalance between joint destruction and repair
- leads to a breakdown of cartilage and bone
- comes with symptoms of pain, stiffness and functional disability

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4
Q

what are some risk factors for developing osteoarthritis?

A
  • advancing age
  • female gender
  • family history
  • obesity
  • quad muscle weakness
  • joint injury/overuse
  • certain occupations
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5
Q

does this decrease a normal joint or an osteoarthritic joint?
- ends of bone are encased in cartilage: hard, smooth coating found at the ends of bone
- articular capsule, ligaments, muscles and tendons: all act to stabilize and protect the joint; joint cavity contains synovial fluid, produced by the synovial membrane

A

normal joint

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6
Q

does this decrease a normal joint or an osteoarthritic joint?
-characterized by abnormalities in the synthesis and degradation of articular cartilage

A

osteoarthritic joint

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7
Q

does this describe early or progressive osteoarthritis?
- joint maintains function by thickening the cartilage

A

early disease

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8
Q

does this describe early or progressive osteoarthritis?
- cartilage erodes away
- subchondral bone exposed (susceptible to trauma)
- joint space narrows
- bone spurs or osteophytes develops: new bone growth in an area away from the damaged area

A

progressive disease

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9
Q

what are some clinical presentations of osteoarthritis

A
  • pain (localized, deep)
  • stiffness
  • crepitation (crackling/grating sound as joint moves)
  • joint enlargement
  • deformity
  • decreased range of motion
  • inflammation
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10
Q

what are the most common joints affected in rheumatoid arthritis and osteoarthritis?

A

rheumatoid: hands (distal joints usually not affected) and feet\

osteoarthritis: neck, lower back, hips, knees, hands (distal portion)

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11
Q

is osteoarthritis usually unilaterally or bilaterally involved?

A

unilaterally

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12
Q

what are some goals of therapy when treating a patient with osteoarthritis?

A
  • relieve symptoms
  • improve mobility and QOL
  • minimize functional disability
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13
Q

when screening for OA, what criteria would be indicative of an OA diagnosis?

A
  • > 45 y/o
  • activity related joint pain
  • no morning joint related stiffness or morning stiffness that lasts <30mins
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14
Q

if new onset joint pain has been present for longer than ___ days, they should be referred to their primary health care provider

A

7-10

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15
Q

what are some red flags that should result in referral for OA

A
  • recent significant trauma
  • acute severe pain
  • minor trauma in elderly or osteoporotic patients (possible fracture)
  • fever or other signs of infection
  • local or diffuse muscle weakness
  • symptoms of burning, numbness or tingling (could be sign of neurogenic pain)
  • inflammation of the joints and/or morning stiffness that lasts > 1hr (could be rheumatoid)

contraindications to self-care:
- chronic liver disease
- history of inflammatory arthritis
- fibromyalgia
- gout

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16
Q

what is the first step for treating OA

A

non pharmacological therapies and topical analgesics (e.g. diclofenac and capsacian)

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17
Q

if there is no improvement with nonpharmacological therapy and topical analgesics, what is the next step?

A

add acetaminophen (max 4g/day)

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18
Q

if there is no improvement when acetaminophen has been added, what is the next step?

A

assess risk for adverse GI events and risk for CV events in order to possibly initiate NSAID treatment

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19
Q

what type of NSAID would be recommended if the patient has low CV risk and low GI risk

A

low-dose nonselective NSAID (e.g. ibuprofen, diclofenac, indomethacin)

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20
Q

what type of NSAID would be recommended if the patient has low CV risk and medium GI risk

A

low dose nonselective NSAID + gastroprotection or low dose celecoxib

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21
Q

what type of NSAID would be recommended if the patient has low dose CV risk and high GI risk

A

low dose celecoxib + gastroprotection

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22
Q

what type of NSAID would be recommended if the patient has medium CV risk and low GI risk

A

low-dose naproxen

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23
Q

what type of NSAID would be recommended if the patient has medium CV risk and medium GI risk

A

low dose naproxen _+ gastroprotection or low dose celecoxib

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24
Q

what type of NSAID would be recommended if the patent has medium CV risk and high GI risk

A

low dose celecoxib + gastroprotection

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25
Q

what type of NSAID would be recommended if the patient has high CV risk and low GI risk

A

consider alternative therapy (e.g. duloxetine or local injections) or low dose naproxen

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26
Q

what type of NSAID would be recommended if the patient has high CV risk and medium GI risk

A

consider alternative therapy (e.g. duloxetine or local injections) or low dose naproxen + gastroprotection

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27
Q

what type of NSAID would be recommended if the patient has high CV risk and high GI risk

A

alternative therapy (e.g. duloxetine or local injections)

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28
Q

if there is no improvement after low dose NSAID’s have been initiated, what is the next step

A

full-dose NSAID + gastroprotection (if clinical appropriate) or supplement with duloxetine or local injections

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29
Q

if full dose NSAIDs don’t provide any relief, what is the next step

A

surgery or supplement with opioids

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30
Q

list some possible non pharmacological options for OA

A
  • weight management
  • physiotherapy
  • strength training and aerobic excercise
  • occupational therapist
  • acupuncture
31
Q

if an individual is >75 years old, what medication is the first line option

A

topical NSAIDs

32
Q

true/false: topical diclofenac are recommended in Tx of OA pain in hands, feet and hips

A

false - only recommended in hands and feet

33
Q

what is the typical dosing of topical diclofenac for OA

A

apply TID-QID for 3-4 weeks to a chief maximum therapeutic effect

34
Q

what are some possible side effects of topical diclofenac

A
  • skin dryness or irritation, hypersensitivity
35
Q

true/false: capsaicin (zostrix) only shows evidence for knee OA

A

true

36
Q

what are some possible adverse effects of zostrix that usually lead to non-adherence

A
  • tingling, burning or redness
    this usually decreases within 72 hrs of repeated use; will not decrease if use PRN
37
Q

this is the long standing DOC for OA; thought to be relatively safe and moderately effective

A

acetaminophen

38
Q

what is the dosing for acetaminophen

A

325mg-1000mg q4-6H PO
Tylenol arthritis (SR): 650mg q8h PO

39
Q

when treating OA pain, how long should the max dose of acetaminophen be used?

A

max therapeutic doses for 2 weeks to assess efficacy, then use to lowest effective dose

40
Q

what should the max dose be for the elderly and if its being chronically used

A

3200mg/day

41
Q

what should the max dose be for those who have cirrhosis or have excessive alcohol use

A

2600mg/day

42
Q

what patient populations is hepatotoxicity risk increased in?

A
  • elderly
  • > 3 drinks/day
  • underlying hepatic disease
43
Q

baseline _____ should be measured in high risk patients if they are taking acetaminophen

A

LFTs

44
Q

this medication is a more effective analgesic than acetaminophen, but due to the risk of serious adverse effects, these are generally reserved for tx after failure of acetaminophen

A

NSAID’s

45
Q

what is the dosing for naproxen

A

220-550 mg BID PO

46
Q

what is the dosing for celecoxib

A

100mg BID PO or 200mg daily

47
Q

why is celecoxib one of the more commonly used NSAIDs?

A

it is a selective cox-2 inhibitor, therefore it has less GI side effects

48
Q

what are some COMMON side effects of NSAIDs

A
  • blasting, nausea, stomach pain, indigestion and heartburn - manage with antacids, H2RAs or PPIs
  • diarrhea or constipation
  • indomethacin has increased CNS side effects such as headache/drowsiness/confusion, especially in the elderly
49
Q

what are some SERIOUS side effects of NSAIDs

A

prior to starting NSAID therapy, assess patients for their risk of CV risks, GI risks and renal complications

50
Q

_____ can increase blood pressure and worsen pre-existing hypertension; therefore baseline and periodic monitoring of blood pressure is necessary

A

NSAIDs

51
Q

All NSAIDs demonstrate an ______ risk of thromboembolic events (MI, stroke); risk is increased with higher doses (Celecoxib >200mg/day, ibuprofen >1200mg/day, naproxen >750mg/day)

A

increased

52
Q

cardiovascular risk increases with COX-__ selectivity; studies suggest risk of CV events is highest in diclofenac, celecoxib and increased doses of ibuprofen

A

1

53
Q

this NSAID has been found to have the lowest risk of CV events

A

naproxen

54
Q

If an NSAID is essential, patients at increased of CV complications should be treated with ______ (and with low dose ASA, if indicated)

A

naproxen

55
Q

this NSAID is associated with a lower incidence of gastrointestinal ulcers; this reduced risk may not extend past 6 months

A

celecoxib

56
Q

either _____ or PPI’s are the recommended options for preventing serious GI complications in patients at risk of NSAID induced ulcer

A

misoprostol

57
Q

_____ may have a higher risk of GI complications

A

naproxen

58
Q

true/false: all NSAIDs increase the risk of impaired renal function and cause cause acute kidney injury, especially when added to antihypertensives like diuretics, ACEi and angiotensin receptor blockers

A

true

59
Q

NSAIDs should be avoided in patients with severe renal impairment with a CrCl of _____ and their prolonged use is not recommended in those with mild-moderate renal impairment

A

< 30mL/min

60
Q

this is an SNRI and may be used as a mono therapy or in combination with NSAIDs for OA of the knee for patients with contraindications to or treatment failure of NSAID therapy

A

duloxetine

61
Q

what is the dosing of duloxetine

A

60mg daily PO (max: 120mg/day)
- should start with 30mg/day and titrate to avoid side effects
- should not be abruptly discontinued

62
Q

what are some adverse effects of duloxetine

A
  • nausea
  • asthenia (physical weakness/lack of energy)
  • constipation
  • diarrhea
  • dry mouth
  • fatigue
  • dizziness
  • headache
  • insomnia
63
Q

reserve ______ as a last line option, particularly for short term pain control for those awaiting surgical intervention; the evidence for these medications in OA is poor and there remains significant concern about toxicity

A

opioids

64
Q

_____ has demonstrated limited efficacy in the treatment of OA. should be reserved as a last line option. causes constipation, dizziness, drowsiness, increased risk of falls and misuse potential

guidelines conditionally recommend the use pf _____ for hand, knee and hip OA, especially in those > 75 y/o

A

tramadol

65
Q

these are natural health products; all guidelines recommend against the use of these agents. they are generally considered safe, with a few drug interactions, but these can potentate the anticoagulant effects of warfarin

A

glucosamine and chondroitin

66
Q

this treatment options response and effect duration is highly variable - some patients describe benefit for days, weeks and some 3-6 months. this can be considered periodically for those who cannot take NSAIDs and do not have optimal control on other agents

A

localized/injectable therapy

67
Q

true/false: localized/injectable therapy is used for knee, hand and hip OA

A

little evidence for hand and hip - used for short term relief in knee OA

68
Q

what is the general rule for the number of injections and patient is limited to for a single joint per year

A

3-4 injections for a single joint per year

69
Q

this treatment option should be reserved for patient who have failed other therapies. costs of these products are high ($200-$400 per treatment course) and they are not routinely covered by insurance plans

A

hyaluronic acid injections

70
Q

when should oral steroids be used for OA?

A

as OA is not a systemic inflammatory condition, oral steroids are not routinely used or recommended

71
Q

when the RPh is monitoring the patients pain relief, how often should they monitor?

A

check in on days 3,7 and 14

72
Q

if the patient has optimal pain control after 3-14 days, what action should the pharmacist take?

A

continue current therapy and find the lowest effective dose

73
Q

if the patient has no improvement in their pain after 14 days, what action should the pharmacist take?

A
  • switch to the alternative agent
  • refer
74
Q

if the patients pain is improving but not optimized, what action should the pharmacist take?

A
  • ensure optimal therapy (maximum therapeutic dose, regular dosing)
  • consider addition of appropriate adjunctive agent (e.g. topical analgesic)

pharmacotherapy 4270 (19 decks)

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