IC16 Management of osteoarthritis and rheumatoid arthritis Flashcards
What is Osteoarthritis (OA)?
OA is a degenerative disease with inflammation of bone & joint cartilage.
What are the risk factors of OA?
- Age
- Gender
- Weight - Obesity
- Genetics
- Joint injury
- Anatomy - misalignment of joints
- - At younger age (<50yo), OA is more likely in men as compared to women - At older age (>50yo), OA is more common in women than men.
What is the process of OA?
- Cartilage damage occurs
- Chondrocytes help to remove/repair damage
- Chondrocytes are the cells responsible for cartilage formation - Abnormal chondrocytes results in more cartilage breakdown
- There is cartilage loss and apoptosis of chondrocytes
- Cartilage shards are formed, causing inflammation of the synovial joints
- Bones rub against each other, causing the formation of osteophytes triggering pain.
- a compensatory structure to stabilise osteoarthritic joints
Based on the process of OA, what are the 3 main pathophysiology of OA?
- Cartilage degeneration
- Bone remodeling & osteophyte formation
- Synovial inflammation
What are the 7 symptoms that a patient w OA presents?
- *Pain
- *Swelling
- *Erythematous & warm
- Morning stiffness <30mins
- Limited joint movement
- Functional limitation
- Asymmetrical polyarthritis - typically on weight bearing joints
What are the distinguishing factors between OA and RA?
OA starts off unilaterally
RA starts of bilaterally.
Erythema of OA is not as obvious or bad as RA.
What are the pain characteristics of OA?
- Pain gets worse w joint use, relieved by rest
- Worse in late afternoon / early evening
- May be associated w anxiety, depression, sleep disturbances
- Severe OA can severely limit functions
- Pain is most severe over the joint line
How to diagnose a pt w OA?
Pt can be diagnosed with OA if they present w typical S&S in the at-risk age group.
E.g of S&S:
- ≥ 45yo
- Activity related joint pain
- Morning stiffness ≤ 30mins
Diagnosis can be done without radiography or lab investigations, if pt has presenting S&S and is of at-risk age group.
Younger pts that do not fall in the at-risk age group require additional testing.
We will have to assess for:
- History of recent trauma
- Rapidly or worsening symptom or deformity
- Concerns of infection or malignancy
What are the goals of therapy of OA?
- Relieve pain
- Improve / preserve rang of motion & joint function
- Improve QoL
What are pharmacological treatments for OA?
- Topical NSAIDs
- Oral NSAIDs + PPIs
- Opioids (tramadol 25-50mg TDS) / Paracetamol
- Glucocorticoids
Do not give glucosamine, chondroitin, fish oil, vitamin D and etc.
To be used at the lowest effective dose, for the shortest possible time.
What are non-pharmacological treatments for OA?
- Low impact exercises - Tai Chi, walking, aquatic aerobics
- Weight loss
- Educate, provide information & support
- Acupuncture
- Walking w a cane
What are some GI concerns with PO NSAIDs?
Prolonged use of PO NSAIDs can cause GI ADRs such as:
- GI bleeding
- GI ulceration
- GI perforation
Common SE:
- Nausea
- Dyspepsia
- Anorexia
- Abdominal pain
What are the risk factors that puts a pt at increased risk of having NSAIDs induced GI ulcer/bleed?
- > 65yo
- History of ulcers
- Use of high dose NSAID OR Use of NSAID long term
- Concurrent use of glucocorticoids, antiplatelets, anticoagulants
If pt presents with ≥ 3 of these 4 risk factors, use -coxibs OR give pt PPI.
Coxibs have lesser propensity to cause GI toxicity as compared to non-selective.
If a pt is suspected to have NSAID-induced GI complications:
- Fatigue
- Severe dyspepsia
- Signs of GI bleed
- Unexplained blood loss anaemia
- Iron deficiency
What should you do?
Refer the patient immediately.
Apart from GI safety concerns, what other concerns are there with regards to PO NSAIDs?
PO NSAIDs can increase the risk of CV events and renal toxicity.
Examples of CV events:
- MI
- Stroke
- Vascular death
Renal toxicity can lead to acute kidney injury.
- *Avoid use of NSAIDs in eGFR <15
- If pt is on diuretics or ACEi/ARBs, avoid PO NSAIDs, or use topical NSAIDs.
- Avoid use tgt w aminoglycosides, amphotericin B, radiocontrast material
What should we do if a patient has an allergy or pseudoallergy to PO NSAIDs?
- Avoid giving all NSAIDs, including coxibs, to pts with allergy
- Avoid giving NSAIDs to pseudoallergic pts. However, Coxibs may still be used w caution.
Can you list out the 9 special populations we should avoid giving PO NSAIDs to?
- Hypersensitivity
- Asthmatic pts
- Pregnant women
- Pt w PUD or GI bleed
- Pt on anticoagulants, antiplatelets, PO glucocorticoids
- Severe renal impairment
- Pt at CVS risk
- Pts w bleeding disorders
- On other NSAIDs already
What is the last resort for treating OA?
Total knee replacement surgery.
Total knee replacement surgery is often used when non-surgical treatment have proven to be ineffective for the pt.
Post rehab is essential for successful outcome.
What is Rheumatoid Arthritis (RA)?
RA is a chronic autoimmune inflammatory systemic disease.
What are risk factors of RA?
- Family history - 3x more at risk is 1st degree relative has RA.
- Genetics - pt w HLA-DRB1 gene have increased likelihood for RA
- Smoking
What is the pathophysiology of RA?
It is the destruction of articular cartilage & underlying bone due to proteases and inflammatory cytokines.
Some examples of inflammatory cytokines involved are:
- TNF
- IL-1
- IL-6
- IL-17
What are some clinical presentation of RA?
- Pain (much more than OA)
- Swelling (much more than OA)
- Erythematous & warm
- Early morning stiffness > 30mins
- Symmetrical polyarthritis
- Joint deformities in severe RA - e.g swan neck, can impair activities of daily living
What are some systemic symptoms of RA?
- Generalized aching/stiffness
- Fatigue
- Fever
- Weight loss
- Depression
What are some lab test that are affected in RA pt?
- Rheumatoid factor, RF
- Anti-CCP
- Erythrocyte sedimentation rate, ESR
- C-reactive protein
- FBC
Note that not all RA pt presents w RF or Anti-CCP. These test may show changes in value but they are not indicative for RA.
