Arthritis and Osteoporosis

Question 1

Describe Osteoarthritis

Answer 1

*degenerative disorder; wear and tear on the joint cartilage
*generally affects WB joints
*generally middle age and beyond
*morning stiffness <30min
*joints are hard with reduced ROM and broken down cartilage
*inflammation is localized to the affected joint
*pain tends to improve with rest
*acetaminophen, NSAIDs

Question 2

Describe Rheumatoid Arthritis

Answer 2

*autoimmune disorder in which the body’s immune system attacks the joints
*Affects joints symmetrically
*mainly middle aged onset
*morning stiffness lasts >30mintues
*joints are swollen, warm, and puffy, with bone erosion
*Systemic inflammation
*pain is worse after periods of inactivity
*Treated with DMARDs, NSAIDs, corticosteroids

Question 3

What is the first line of treatment for pain relief in OA? What is the MOA, SE, and possible toxicities?

Answer 3

The first line of medication for OA is acetaminophen.
MOA: Believed to reduce PG production in the brain.
SE: nausea, vomiting, loss of appetite, allergic reaction
Toxicities: liver damage

Question 4

What are the most common NSAIDs used for OA?

Answer 4

*Ibuprofen
*Naproxen sodium
*Celecoxib
*Diclofenac
*Meloxicam

Question 5

What is the MOA and side effects of NSAIDs?

Answer 5

MOA: NSAIDs work by inhibiting the activity of COX-1 and COX-2 which produce PGs thus decreasing inflammation and pain.
SE: GI (ulcers, bleeding, heartburn), Cardio (risk of heart attack or stroke with prolonged use), renal (failure or retention)

Question 6

What is the MOA and side effects of hyaluronic acids (HA)?

Answer 6

MOA: When injected into the joint, it acts as a lubricant and shock absorber and helps reduce pain by reducing friction
SE: pain at injection site, joint stiffness, headache

Question 7

what is the MOA and SE of Chondroitin Sulfate?

Answer 7

MOA: Helps prevent the breakdown of cartilage and stimulate its repair mechanisms, helps improve consistency of synovial fluid
SE: stomach pain, nausea, diarrhea, constipation, headache, swelling of eyes

Question 8

Damage to the bone and cartilage caused by intense episodic synovitis in RA can be attributed to…

Answer 8

proinflammatory mediators known as cytokines that include interleukin-1 (IL-1) and tumor necrosis factor-a (TNF-a)

Question 9

Describe DMARDs for the treatment of RA

Answer 9

MOA: inhibit autoimmune response including production of cytokines (ILs, IFNs, TNF) and cellular activation (monocytes, T and B lymphocytes)
Traditional: restrict immune system broadly
Targeted: block precise pathways inside immune cells

Question 10

What is the MOA and adverse effects of corticosteroids?

Answer 10

MOA: general immunosuppression, reduce proinflammatory cytokines
AE: Fluid retention, hyperglycemia, weight gain, osteoporosis, Fx

Question 11

What is the MOA and adverse effects of hydroxychloroquine?

Answer 11

MOA: not well understood
AE: retinal damage, rash, diarrhea

Question 12

What is the general MOA and AW of TNF-a blockers (Entercept, Infliximab, Adalimumab, Certolizumab, and golimumab)

Answer 12

MOA: TNF-a inhibitor or antibody to TNF-a
AE: Local injection site reactions, infection, malignancy

Question 13

What are PT considerations for patients on DMARDs?

Answer 13

DMARDs may cause fatigue, reduced exercise tolerance, injection site reactions, bone demineralization (need WB exercises)

Question 14

What is the role of parathyroid hormone?

Answer 14

Promotes bone resorption by stimulating the osteoclasts.
Enhances renal retention of Ca+ and renal phosphate excretion.
PTH given in low and intermittent doses increases bone formation

Question 15

what is the principal regulator of PTH?

Answer 15

Ca+ is the primary regulator of PTH
When there is excess PTH= increase bone resorption

Question 16

what is the role of calcitonin?

Answer 16

lowers blood levels of Ca+ and phosphate by inhibiting osteoclasts

Question 17

what is the function of osteoblasts vs osteoclasts

Answer 17

osteoblasts: form bone tissue
osteoclasts: destroy bone matrix

Question 18

PTs should encourage patients with osteopenia or osteoporosis to….

Answer 18

obtain adequate calcium and vitamin D intake as dietary sources or
supplements

Question 19

What agents target osteoclast function?

Answer 19

Antiresorptive agents:
bisphosphonates, estrogen replacement therapy, SERM (ie, raloxifene),
and calcitonin

Question 20

what anabolic agent targets and increases function and activity of osteoblasts?

Answer 20

Teriparatide

Question 21

What is the MOA, side effects , and clinical use of bisphosphonates?

Answer 21

MOA: inhibit bone resorption by binding to hydroxyapatite and preventing osteoclast activity
SE: GI disturbances, osteonecrosis of the jaw, atypical femur fx
clinical use: first line treatment for post menopause osteoporosis and glucocorticoid induced osteoporosis
SHOULD BE TAKEN 1 HOUR PRIOR TO PT

Question 22

what are common bisphosphonate drugs?

Answer 22

Alendronate, Risedronate, Ibandronate, Zoledronic acid

Question 23

What is the MOA, side effects, and clinical use of SERMs?

Answer 23

Raloxifene
MOA: mimic estrogen in bone, reduce bone resorption without stimulating breast or uterine tissue
SE: hot flashes, leg cramps, increased VTE
clinical utility: prevent and treat post menopause osteoporosis.

Question 24

What is the MOA and side effects of calcitonin?

Answer 24

MOA: Decrease blood calcium level and inhibit osteoclast activity and reduce bone resorption.
SE: nasal irritation, hot flashes

Question 25

What is the MOA, side effects , and clinical use of PTH analogs?

Answer 25

Teriparatide
MOA: stimulate osteoblast activity to promote bone formation
SE: leg cramps, dizziness, nausea
clinical utility: used for high risk patients with previous osteoporotic fx (only for pts at a high risk of fx)

Question 26

What is the MOA, side effects , and clinical use of monoclonal antibodies?

Answer 26

Denosumab
MOA: binds and inhibits RANKL, reducing osteoclast formation, function, and survival
SE: skin reactions at injection site, osteonecrosis of the jaw, hypocalcemia
clinical use: for post menopause women at a high risk of fx

Question 27

what is the role of vitamin D and bone?

Answer 27

1. Bone Mineralization: Vitamin D helps in the absorption of calcium from the gut. A deficiency in vitamin
   D can result in decreased calcium absorption, leading to a decrease in the calcium available for bone
   mineralization.
2. Parathyroid Hormone (PTH) Regulation: Low levels of vitamin D can stimulate the parathyroid gland to
   produce more PTH Elevated PTH can lead to increased bone resorption, making bones more fragile.

Question 28

what is the role of calcium and bone?

Answer 28

1. Direct Role in Bone Structure: Calcium is a primary mineral in bone, forming hydroxyapatite crystals,
   which give bone its hardness.
2. Extracellular Calcium Regulation: If dietary calcium is insufficient, the body will extract calcium from the bones to maintain extracellular calcium levels, which can weaken the bones.