Arthritis Flashcards
Non-pharmacologic tx of OA
Patient education, lose weight (1 lb of weight loss reduces weight on knees by 4 lb), low-impact aerobic exercise, increase muscle, heat, ice for acute injuries (RICE), acupuncture/TENS for knee OA, joint protection with OT/PT, surgery
Treatment of OA
Acetaminophen, NSAIDs/salicylates, intra-articular and oral corticosteroids, intra-articular hyaluronan for knee OA, topical analgesic creams, tramadol, opiods
Initial treatment for hand OA
-Topical capsaicin
-Topical NSAIDs (patients >75)
-Oral NSAIDs
-Tramadol
Avoid opioids and corticosteroid joint injections
Initial treatment for knee OA
- Tylenol QID-TID
- Topical NSAIDs
- Oral NSAIDs
- Tramadol
- Corticosteroid joint injections
- IF unable to do replacement, opioids and duloxetine (conditional)
Avoid capsaicin, glucosamine, chondroitin
No recommendation for hyaluron
Initial treatment for hip OA
- Tylenol QID-TID
- Oral NSAIDs (no topical)
- Tramadol
- Corticosteroid joint injections
Avoid glucosamine, chondroitin
No recommendation for hyaluron, topical NSAIDs, duloxetine, opioids
Use opioids if unable to do surgery.
Tylenol
Analgesia and antipyretic, symptomatic relief.
Toxicity concerns in senior population, hepatotoxicity.
Should be first line because of safety.
People prefer NSAIDs, they were more effective. (GI issues)
Hyaluronan
Substitute for hyaluronic acid in the joint fluid.
Intra-articular for knee OA.
Worked better for senior patients with severe OA.
Approved as a medical device.
Benefit for 6 mo - 1 year.
Expensive.
Application of analgesic creams
Avoid applying after exercise/hot shower, avoid with heating pads or occlusive bandages, use one cream at a time, wash hands after, discontinue if skin rash or prolonged continuing pain
NSAIDs
RA doses higher than OA
Decrease prostaglandin synthesis via inhibition of COX-2, resulting in decreased inflammation
Celecoxib
Cox-2. Black box warning for GI side effects.
CROSS ALLERGY with ASA/NSAIDs, sulfonamide side chain CI with sulfonamide allergies.
Less likely to cause GI ulcers.
Use for patients without risk factors for CV disease, but risk factors for GI ulcer.
Hydroxychloroquine
Antimalarial, used in combo with DMARDs.
Delayed onset of action, potent anti-inflammatory effects. Do not prevent progression of RA.
Decreases HIV viral load, decreases diabetes risk.
SE: retinal toxicity, photosensitivity/pigmentation/rashes, itching, teratogenicity, nausea/diarrhea, rare bone marrow suppression.
Monitoring with anti-malarials
Baseline eye exam, CBC, ADR, joint evaluation
Anti-malarial eye exams
Low risk: Baseline and annual after 5 years. Toxicity risk rises after cumulative 1000 mg dose.
High risk: Annual. Over 60, eye disease, liver/renal disease, high dose, > 5 years of treatment.
MTX basics
FIRST DMARD of choice
High response rate
Onset within 1 month, significant benefit at 3 months, plateaus after 6-12 months.
Disease returns after 1 month of stopping.
Patients who initially respond to MTX then deteriorate usually don’t respond to higher doses.
MTX dosing
Initially 7.5-15 mg/week PO/IM/SQ Intermittent weekly schedule decreases hepatic toxicitiy Increase by 2.5-5 mg/week Q4weeks Max 20-25 mg/week Decrease to lowest maintenance dose
