3. Osteoarthritis MT1 Flashcards
is osteoarthritis an inflammatory or noninflammatory disorder
noninflammatory
osteoarthritis is a disease of the _____ joints
synovial
true/false: osteoarthritis is due to daily “wear and tear” - due to excessive & repetitive force on the cartilage joints
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
what are some risk factors for developing osteoarthritis?
- advancing age
- female gender
- family history
- obesity
- quad muscle weakness
- joint injury/overuse
- certain occupations
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
normal joint
does this decrease a normal joint or an osteoarthritic joint?
-characterized by abnormalities in the synthesis and degradation of articular cartilage
osteoarthritic joint
does this describe early or progressive osteoarthritis?
- joint maintains function by thickening the cartilage
early disease
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
progressive disease
what are some clinical presentations of osteoarthritis
- pain (localized, deep)
- stiffness
- crepitation (crackling/grating sound as joint moves)
- joint enlargement
- deformity
- decreased range of motion
- inflammation
what are the most common joints affected in rheumatoid arthritis and osteoarthritis?
rheumatoid: hands (distal joints usually not affected) and feet\
osteoarthritis: neck, lower back, hips, knees, hands (distal portion)
is osteoarthritis usually unilaterally or bilaterally involved?
unilaterally
what are some goals of therapy when treating a patient with osteoarthritis?
- relieve symptoms
- improve mobility and QOL
- minimize functional disability
when screening for OA, what criteria would be indicative of an OA diagnosis?
- > 45 y/o
- activity related joint pain
- no morning joint related stiffness or morning stiffness that lasts <30mins
if new onset joint pain has been present for longer than ___ days, they should be referred to their primary health care provider
7-10
what are some red flags that should result in referral for OA
- 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
what is the first step for treating OA
non pharmacological therapies and topical analgesics (e.g. diclofenac and capsacian)
if there is no improvement with nonpharmacological therapy and topical analgesics, what is the next step?
add acetaminophen (max 4g/day)
if there is no improvement when acetaminophen has been added, what is the next step?
assess risk for adverse GI events and risk for CV events in order to possibly initiate NSAID treatment
what type of NSAID would be recommended if the patient has low CV risk and low GI risk
low-dose nonselective NSAID (e.g. ibuprofen, diclofenac, indomethacin)
what type of NSAID would be recommended if the patient has low CV risk and medium GI risk
low dose nonselective NSAID + gastroprotection or low dose celecoxib
what type of NSAID would be recommended if the patient has low dose CV risk and high GI risk
low dose celecoxib + gastroprotection
what type of NSAID would be recommended if the patient has medium CV risk and low GI risk
low-dose naproxen
what type of NSAID would be recommended if the patient has medium CV risk and medium GI risk
low dose naproxen _+ gastroprotection or low dose celecoxib
what type of NSAID would be recommended if the patent has medium CV risk and high GI risk
low dose celecoxib + gastroprotection
what type of NSAID would be recommended if the patient has high CV risk and low GI risk
consider alternative therapy (e.g. duloxetine or local injections) or low dose naproxen
what type of NSAID would be recommended if the patient has high CV risk and medium GI risk
consider alternative therapy (e.g. duloxetine or local injections) or low dose naproxen + gastroprotection
what type of NSAID would be recommended if the patient has high CV risk and high GI risk
alternative therapy (e.g. duloxetine or local injections)
if there is no improvement after low dose NSAID’s have been initiated, what is the next step
full-dose NSAID + gastroprotection (if clinical appropriate) or supplement with duloxetine or local injections
if full dose NSAIDs don’t provide any relief, what is the next step
surgery or supplement with opioids
list some possible non pharmacological options for OA
- weight management
- physiotherapy
- strength training and aerobic excercise
- occupational therapist
- acupuncture
if an individual is >75 years old, what medication is the first line option
topical NSAIDs
true/false: topical diclofenac are recommended in Tx of OA pain in hands, feet and hips
false - only recommended in hands and feet
what is the typical dosing of topical diclofenac for OA
apply TID-QID for 3-4 weeks to a chief maximum therapeutic effect
what are some possible side effects of topical diclofenac
- skin dryness or irritation, hypersensitivity
true/false: capsaicin (zostrix) only shows evidence for knee OA
true
what are some possible adverse effects of zostrix that usually lead to non-adherence
- tingling, burning or redness
this usually decreases within 72 hrs of repeated use; will not decrease if use PRN
this is the long standing DOC for OA; thought to be relatively safe and moderately effective
acetaminophen
what is the dosing for acetaminophen
325mg-1000mg q4-6H PO
Tylenol arthritis (SR): 650mg q8h PO
when treating OA pain, how long should the max dose of acetaminophen be used?
max therapeutic doses for 2 weeks to assess efficacy, then use to lowest effective dose
what should the max dose be for the elderly and if its being chronically used
3200mg/day
what should the max dose be for those who have cirrhosis or have excessive alcohol use
2600mg/day
what patient populations is hepatotoxicity risk increased in?
- elderly
- > 3 drinks/day
- underlying hepatic disease
baseline _____ should be measured in high risk patients if they are taking acetaminophen
LFTs
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
NSAID’s
what is the dosing for naproxen
220-550 mg BID PO
what is the dosing for celecoxib
100mg BID PO or 200mg daily
why is celecoxib one of the more commonly used NSAIDs?
it is a selective cox-2 inhibitor, therefore it has less GI side effects
what are some COMMON side effects of NSAIDs
- 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
what are some SERIOUS side effects of NSAIDs
prior to starting NSAID therapy, assess patients for their risk of CV risks, GI risks and renal complications
_____ can increase blood pressure and worsen pre-existing hypertension; therefore baseline and periodic monitoring of blood pressure is necessary
NSAIDs
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)
increased
cardiovascular risk increases with COX-__ selectivity; studies suggest risk of CV events is highest in diclofenac, celecoxib and increased doses of ibuprofen
1
this NSAID has been found to have the lowest risk of CV events
naproxen
If an NSAID is essential, patients at increased of CV complications should be treated with ______ (and with low dose ASA, if indicated)
naproxen
this NSAID is associated with a lower incidence of gastrointestinal ulcers; this reduced risk may not extend past 6 months
celecoxib
either _____ or PPI’s are the recommended options for preventing serious GI complications in patients at risk of NSAID induced ulcer
misoprostol
_____ may have a higher risk of GI complications
naproxen
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
true
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
< 30mL/min
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
duloxetine
what is the dosing of duloxetine
60mg daily PO (max: 120mg/day)
- should start with 30mg/day and titrate to avoid side effects
- should not be abruptly discontinued
what are some adverse effects of duloxetine
- nausea
- asthenia (physical weakness/lack of energy)
- constipation
- diarrhea
- dry mouth
- fatigue
- dizziness
- headache
- insomnia
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
opioids
_____ 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
tramadol
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
glucosamine and chondroitin
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
localized/injectable therapy
true/false: localized/injectable therapy is used for knee, hand and hip OA
little evidence for hand and hip - used for short term relief in knee OA
what is the general rule for the number of injections and patient is limited to for a single joint per year
3-4 injections for a single joint per year
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
hyaluronic acid injections
when should oral steroids be used for OA?
as OA is not a systemic inflammatory condition, oral steroids are not routinely used or recommended
when the RPh is monitoring the patients pain relief, how often should they monitor?
check in on days 3,7 and 14
if the patient has optimal pain control after 3-14 days, what action should the pharmacist take?
continue current therapy and find the lowest effective dose
if the patient has no improvement in their pain after 14 days, what action should the pharmacist take?
- switch to the alternative agent
- refer
if the patients pain is improving but not optimized, what action should the pharmacist take?
- ensure optimal therapy (maximum therapeutic dose, regular dosing)
- consider addition of appropriate adjunctive agent (e.g. topical analgesic)
