Bone/Joint Disorders-recaps

Question 1

OA abbr

Answer 1

osteoarthritis

Question 2

OA characteristics

Answer 2

-slow onset
-after age of 50
-minimal inflammation
-pain in hips, knees, hands (symmetrical/asymmetric_- +/- bony enlargements

Question 3

OA: therapy

Answer 3

rest, weight loss (if overweight), exercise (low impact, aerobic, strength training), heat/ice, occupational/physical therapy (OP/PT), surgery

Question 4

hallmark of OA

Answer 4

morning stiffness lasting <30 minutes

Question 5

mild-moderate OA: first-line therapy

Answer 5

APA
325-650mg po q4-6h (max 4g/day)

2-3g/day if >75 years
duration: 4-6wk

Question 6

max 2g of APA is recommended for

Answer 6

-heavy alcohol use
-malnutrition
-fasting
-low body wt
-advanced age
-febrile illness

Question 7

NSAIDs

Answer 7

-if APAP fails
for moderate-severe OA
-lowest dose, avoid long-term

Question 8

cox-2

Answer 8

equally effective but not more than non-selective NSAIDs

reserved for high risk GI events

Question 9

increased CV risk w/

Answer 9

cox-2 inhibitors
&
NSAIDs such as diclofenac vs non-selective NSAIDs

Question 10

control pain and reduce GU risk

Answer 10

acetaminophen in combo w/ lose-dose naproxen or ibuprofen

Question 11

glucosamine and chondroitin

Answer 11

no more effective than placebo in decreasing pain; in context of study limitations: modest reduction in pain & impr mobility

compared to turmeric (curcumin), white willow bark, MSM, SAMe

Question 12

intra-articular injections

Answer 12

may be considered as initial management , esp in patients w/ mod-severe pain refractory to oral analgesic/anti-inflam agents

Question 13

corticosteroids

Answer 13

onset in days but duration does not persist for beyond 4 wk

-serial injections (q3m) not recommended

Question 14

hyaluronic acid

Answer 14

a viscous substance believed to facilitate joint lubrication and shock absorption
-effect persists for longer than the residence time in the synovium
-greater pain relief than corticosteroids, but longer time to onset

Question 15

tramadol / opioids

Answer 15

reserved for mod - severe pain, which impairs fn/quality of life for which potential benefits outweigh risks
-unresponsive to other therapies
-when other therapies are contraindicated

Question 16

opioids (inc tramadol) should be initiated with

Answer 16

short-acting agents at low doses and titrated to the lowest effective dose
-combine w/ acetaminophen or NSAIDs to reduce the opioid requirement
-clinicians should est realistic pain & fn goals
-response to opioid therapy s/b assessed w/i 1-4 wk of initiation or dose inc and every 3m after

Question 17

tramadol is

Answer 17

a centrally-acting synthetic opioid agonist (weak mu receptor), SNRI (mimics duloxetine, venlafaxine)

-post-op, neuropathic, lower back pain, labor, fibromyalgia, OA, cancer

Question 18

tramadol: a/e

Answer 18

-increase seizure risk
-serotonin syndrome
-similar to opioid

Question 19

duloxetine

Answer 19

SNRI, FDA-approved for chronic musculoskeletal pain, including OA

-beneficial for concomitant neuropathic pain
-not for hepatic insuff., excessive alcohol use, or severe renal impairment (creatinine clearance <30 mL/min)
-geriatric pts at greater risk for hyponatremia
-urinary hesitation and urinary retention
-orthostatic hypotension, esp w/i the 1st wk of therapy

Question 20

duloxetine - concomitant use

Answer 20

w/ tramadol

watch for serotonin syndrome