ic16 osteoarthritis management Flashcards

1
Q

RISK factors for osteoarthritis

A

genetic disposition (rare mutations in collagens type II, IX, XI; GDF-5)

anatomic factors (bow legged, knocked knee; varus and valgus alignment )

joint disease from sports or injury

obesity

aging

gender (<50 M>F; >70 F>M)

occupation

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2
Q

clinical presentation of OA

A

pain USUALLY ON MOTION

(less swelling, erythema, and warmth compared to RA)

morning stiffness <30min (maybe)

limited joint movement

functional limitation/instability

asymmetrical polyarthritis (typically weight bearing joints of hand (distal joints eg DIP, PIP; spare wrist or MCP), knee, or hip)

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3
Q

characteristics of oa

A

slow onset over years
pain is worse with joint use, relieved with stress

typically in the late afternoons or early evening; could be related to weather?

more severe over the joint line

knee; worse going down stairs or slope compared to going up

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4
Q

stages of OA

A

stage 1: predictable sharp pain with mechanical insult = limits high impact activities and modest effect on function

stage 2: pain becomes more constant, with unpredictable episodes of stiffness = WOL affected

stage 3: constant dull or aching pain with episodes of unpredictable exhausting pain

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5
Q

physical exam for OA?

A

bone related
asymmetric monoarticular or oligoarticular
palpable warmth
bone tenderness
bone enlargement

transient joint effusion

motion related
- crepitus on motion
- reduced range of motion

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6
Q

radiographic findings for oA

A

joint space narrowing
marginal osteophytes
subchondral bone sclerosis (thickening of the joint under cartilage)
abnormal alignment of joint

USUALLY only in advanced disease

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7
Q

lab findings for OA

A

ESR <20 mm/h
usually significant inflammation = >20

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8
Q

when is diagnosis not required

A

if ≥45yo
if activity related joint pain (in one or few joints)
morning stiff ≤30min

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9
Q

when should additional testing be done

A

younger individuals
presence of atypical s/sx
- hx of recent trauma
- rapidly worsening symptoms or deformity
- concerns of infection or malignancy = weight loss, fever…

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10
Q

what are the 1st line non phx treatment recommendations for OA

A

exercise (all three)

knee and hip = weight loss, Tai Chi, cane

can consider 1st CMC orthosis for hand…
can consider knee brace for knee OA

  • some evidence for heat or therapeutic cooling…
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11
Q

what are the 1st line phx treatment recommendations for oa

A

low dose, short term oral NSAIDs (all three)
consider topical for knee
- hip = too deep; hand = washed off
intra-articular steroids for knee or hip

low evidence for paracetamol, tramadol, duloxetine

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12
Q

what kind of exercises can be done for OA

A

1) STRENGTHENING
2) neuromuscular training
3) low impact aerobics eg walking or swimming
4) tai chi
FOR ATLEAST 30MIN, 3X PER WEEK

refer to physio for
- supervised exercises = better outcomes
- splints/braces, thermal therapy

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13
Q

dosing for NSAIDs

A

diclofenac 50mg q8-12 max 150
indomethacin 25-50mg q8-12 max 150
mefenamic acid 250 q6 max 1000

ibuprofen 400mg q4-6, max 3200 acute; 2400 chronic
ketoprofen 50mg q6 max 300
naproxen 250-500 q12, mx 1250 acute, 1000 chronic
naproxen sodium 275-550mg q12, max 1100 chronic, 1375 acute

celecoxib 200mg OD, max 400
etoricoxib 30-60mg OD, max 120 acute 60 chronic

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14
Q

risk factors for GI toxicity of NSAIDs and management

A

if 3 of more of these factors
- >65yo
- history of ulcer
- use of high dose or chronic NSAIDs
- concurrent GC/ antiplatelet/anticoagulants

= use coxib or add PPI

gi bleed, ulcer, perforation

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15
Q

suspected NSAID induced GI complications

A

fatigue sx
severe dyspepsia
signs of gi bleeding
unexplained blood loss, anemia
iron deficiency

= refer immediately…

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16
Q

cvs dosing limitations for nsaids

A

mi stroke vascular death

celecoxib use at doses <400mg/day
diclofenac <150mg/day

for patients with established CVD: CHF, IHD, uncontrolled hypertension

17
Q

renal toxicity concerns for NSAIDs

A

risk facotrs for AKI

1) CKD avoid if eGFR <15; can use 5-7 days max if 15-60
2) true volume depletion (emesis, diarrhoea. sepsis, haemorrhage)
3) effective depletion: HF, nephrotic syndorme, cirrhosis
4) aminoglycosides, amphotericin B, radio-contrast media
5) diuretics and ACEi/ARB
6) >65yo

avoid PO nsaids, can consider topical…
if really needed, monitor SCr and electrolyte…

18
Q

allergic/pseudoallerigc considerations

A

can use coxibs if not serious

if serious then avoid all

avoid in asthma (caution with cox2 selective)

19
Q

what are the possible pseudoallergic reactions

A

bronchospasm
urticaria
angioedema
anaphylaxis…

20
Q

hematological considerations for NSAIDs

A

inhibits platelet function, stop 3 days before surgery
(1 week for aspirin)

avoid in haemophilia

21
Q

cns complaints for nsaids

A

some complaints of drowsiness dizziness headaches tinnitus..

22
Q

pregnancy considerations for nsaids

A

avoid in pregnancy, especially 3rd trimester…

23
Q

what tramadol dose to give and when

A

mod to severe pain
25-50mg TDS
max 400mg per day
only when contraindicated to NSAIDs

24
Q

dose of IA GC, how long and when

A

mod to severe pain
contra/failure of NSAIDs
DO NOT USE ROUTINELY, short term 4-6 weeks only

25
Q

contraindications for IA GC

A

periarticular infection
sepsis arthritis
periarticular fracture
joint instability
juxta-articular osteoporosis

26
Q

dosing for IA GC

A

METHYLPREDNISOLONE ACETATE
small: 10-20mg (finger joints)
med: 40-60mg (wrist ankle elbow)
large: 40-80mg (knee shoulder hip)

TRIAMCINOLONE ACETONIDE
small: 8-10mg
20-30mg
20-40mg

27
Q

duloxetine considerations

A

mod-severe if contra or failure of NSAIDs

possibly used w concomitant depression?

however consider the SNRI side effects

28
Q

topical capsaicin moa?

A

initial enhanced stimulation of TRPV1 expressing cutaneous nociceptors = painful sensations follwoed by pain relief mediated by a reduction in TRPV1 expressing nociceptive endings

29
Q

considerations for topical capsaicin including side effects

A

efficacy unknown
do not use for more than 5 days if patch

may cause burning, erythema, pain…

30
Q

When to consider surgery

A

total joint arthroplasty
if
QOL substantially affected
non surgical treatment not effective

31
Q

contraindications for TJA

A

ACTIVE INFECTION = check ESR, CRP, joint aspiration, MRI

chronic lower extremity ischamia

skeletal immaturity

32
Q

INDOMETHACIN considerations

A

has potent inhibitory effects on renal PGI2 synthesis

and also is associated with CNS side effects like headache and altered mental status (compared to other NSAIDs)

33
Q

which nsaids are associated with skin reactions

A

oxicam nsaids (meloxicam, piroxicam)
sulindac,
diflunisal