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54 Finals > IC16 OA > Flashcards

IC16 OA Flashcards

1
Q

Urgent referrals

A

infection, trauma, malignancy related causes

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2
Q

definition of OA

A

degenerative disease (with inflammation) of bone and joint cartilage

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3
Q

prevalence of OA

A
  • increases with age (more wear and tear over time)
  • <50yo: men > women (possibly sports, other injuries)
  • > 70yo: women > men (esp OA in hands)
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4
Q

RF of OA

A
  • Genetics, Anatomical factors
  • Joint injury (eg sports, surgery)
  • Obesity (weight bearing joints)
  • Ageing
  • Gender, occupation
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5
Q

Pathophysiology of OA

A

Due to wear tear causing secondary inflammation
- Cartilage degradation
- Bone remodelling and osteophyte formation
- Synovial inflammation

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6
Q

Clinical presentations

A
  • Pain, swelling (from joint effusion), erythematous (unlikely to see redness, more in RA), warm
  • Morning stiffness <30mins
  • Limited joint movement
  • Functional limitation/ instability
  • Asymmetrical polyarthritis (typically weight bearing joints): hand (DIP fingers), knee, hip
  • Crepitus on motion — noise when you move joints
  • Reduced range of motion
  • Bone enlargement due to osteophyte formation
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7
Q

Characteristic of pain in OA

A
  • slow progression over the years, does not have obvious sx at first
  • worse with joint use, relieved by rest
  • (knees) worse going down stairs/slope compared to going up
  • worse in late afternoon/ early evening
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8
Q

3 stage of pain in OA

A
  • Stage 1: predictable sharp pain with mechanical insult (pain when use)
  • Stage 2: constant pain with unpredictable episodes of stiffness (affect daily activities)
  • Stage 3: constant dull/aching pain with episodes of unpredictable intense pain (severe limitation in function)
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9
Q

dx of OA

A

may be dx w/o radiography and/or lab investigation

No imaging needed if:
- ≥45yo
- activity-related joint pain (in one or a few joints)
- Sx of OA eg morning stiffness ≤30mins

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10
Q

Additional testing to be considered in:

A
  • younger individuals
  • presence of atypical S/S suggesting alternative dx
    • Hx of recent trauma
    • Rapidly worsening symptoms or deformity
    • Infection, malignancy
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11
Q

Goals of tx in OA

A
  • Relieve pain & inflammation — pharmacological
  • Improve/ preserve range of motion and joint function — non-pharm
  • Improve OQL
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12
Q

non pharm for OA

A
  • Exercise (30mins, 3x per week) — can reduce pain and improve physical function -> strengthening, neuromuscular training, low impact aerobic (brisk walking, swimming), mind body (Tai Chi) [referral to physiotherapists if needed]
  • Weight management — improve QOL and physical function, reduce pain (reduce load on weight bearing joints)
  • Information support — engage and empower
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13
Q

Common sites of OA

A

hand, knee, hips

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14
Q

when can Topical NSAIDs be used

A

knee, maybe hand OA, not for hip

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15
Q

eg of topical NSAIDs

A

Diclofenac gel, Ketoprofen gel/plaster

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16
Q

SE of topical NSAIDs

A

local irritation (eczema, open wound, psoriasis), photosensitivity

17
Q

PO NSAIDs/ coxib when are they used

A

(consider if topicals are not effective/suitable)
- Consider potential GI, CVS, renal toxicity and CI
- Use lowest effective dose and only when needed
- add PPI prophylaxis with PO NSAID use (>3 out 4 RF)

18
Q

what medications can be used if NSAIDs are CI

A
  • PO paracetamol/ tramadol/ duloxetine
  • Intraarticular (IA) glucocorticoid injections
19
Q

SE of PO NSAIDS (general)

A
  • GI
  • Renal
  • CV
  • Allergic rx
  • Pseudo allergy
  • Haematological (bleeding)
20
Q

GI common SE and GI toxicity SE

A

Common SE: nausea, dyspepsia, anorexia, abdominal pain → take med with food

GI toxicity: GI bleed, ulceration, perforation → see Dr immediately

21
Q

RF for NSAID induced GI bleed

A
  • > 65 yo
  • hx of ulcer
  • high dose/ chronic NSAID use
  • concomitant GC/antiplatelet/anticoagulation
22
Q

when should PPI/ coxib be added to NSAID to prevent GI toxicity?

A

≥3 of these 4 RF OR hx of complicated ulcer (bleed) → use coxib/ add PPI

23
Q

Urgent referral needed when NSAID induced GI complications

A
  • Fatigue sx
  • Severe dyspepsia
  • GI bleeding (melena)
  • Unexplained blood loss anemia
  • Iron deficiency
24
Q

Considerations for NSAID use with GI SE

A
  • Ibuprofen has less GI SE compared to naproxen
  • coxib (eg celecoxib, etoricoxib) preferred if high risk of GI bleed/ulcer
  • Paracetamol used if NSAID/ coxib cannot be used
25
Q

CV SE with NSAIDs

A

MI, stroke, HTN, vascular death

26
Q

Pathophysiology of CV SE and mx

A
  • due to COX 2 inhibition mechanism: renal effects causing HTN + risk of prothrombotic effects
  • occurs in both selective and non-selective NSAIDs
  • Mx: use celecoxib at doses <400mg/day (200mg/d recommended)
27
Q

Renal SE and RF

A

AKI
Risk factors for NSAID induced AKI:
- CKD: avoid NSAID/ coxib in eGFR <15
- Volume depletion: vomiting/emesis, diarrhoea, sepsis, haemorrhage
- Effective arterial volume depletion (decr cardiac output): HF, nephrotic syndrome (pass out too much protein), cirrhosis
- Severe hypercalcemia/ renal artery stenosis
- Concomitant nephrotoxic drugs: aminoglycosides, amphotericin B, radiocontrast material
- Diuretics, ACEI/ARB (also: hyperkalemia, hyponatremia)
- >65yo

28
Q

Mx of renal SE

A

use topical NSAID except in nephrotic syndrome, monitor SCr and electrolytes if NSAID use is unavoidable
- If pt is renally impaired on dialysis: can give NSAIDs if really needed (not on dialysis, avoid)

29
Q

Allergic reactions vs pseudo allergic rx

A
  • Allergic reactions (IgE mediated): urticaria, angioedema, anaphylaxis (can give NSAID of different structure, Avoid all NSAID/coxib if anaphylaxis is involved)
  • Pseudoallergic reactions (non-immunologic, related to COX-1 inhibition): same S/S (avoid all NSAIDs, use coxib with caution)
30
Q

Mx of allergic rx

A
  • avoid all non-selective NSAID
  • if rx is severe (anaphylaxis/ difficulty breathing) avoid all coxib also
  • Asthma: avoid all non-selective NSAIDs, can give coxibs with caution
31
Q

Bleeding/Haematological effects of NSAIDs
- When to stop tx before surgery?

A
  • Inhibits platelet function
  • Stop NSAID 3 days before surgery (aspirin stop 1 week prior)
32
Q

Tramadol dose in OA, what level of pain is it being used?

A

Tramadol (for moderate to severe pain): 25-50mg TDS (max 400mg)
- used after surgery also

33
Q

Duration for Intraarticular glucocorticoid injections

A

short term (4-6 weeks) relief
- for moderate to severe pain & CI/failure with NSAIDs
- no evidence of long term benefit with regular use (routine use NOT recommended)

34
Q

CI for IA GC injections

A
  • periarticular infection
  • septic arthritis
  • periarticular fracture
  • joint instability
  • juxta-articular osteoporosis
35
Q

Duloxetine indication and SE

A
  • for moderate to severe pain & CI/failure with NSAIDs
  • SE: SNRI SE
36
Q

topical capsaicin SE

A

cause application site reaction (eg burning, erythema, pain)

  • Patch: do not use for >5 consecutive days
  • MOA: agonist for TRPV1 (enhance painful sensation → followed by pain relief mediated by a reduction in TRPV1 expressing nociceptive nerve endings)
37
Q

Surgical tx for OA, when is it considered?

A

total joint arthroplasty/replacement: considered where QOL severely affected, non-surgical tx is ineffective/ unsuitable

38
Q

postoperative mx after surgery

A

postoperative rehabilitation is essential for successful outcome (help pt use new joint quickly)
- analgesic given (usually tramadol) for pain relief so that pt can undergo rehabilitation

39
Q

CI for OA surgery

A

active infection, chronic lower extremity ischemia, skeletal immaturity

54 Finals (7 decks)

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