ic16 osteoarthritis management Flashcards
RISK factors for osteoarthritis
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
clinical presentation of OA
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)
characteristics of oa
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
stages of OA
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
physical exam for OA?
bone related
asymmetric monoarticular or oligoarticular
palpable warmth
bone tenderness
bone enlargement
transient joint effusion
motion related
- crepitus on motion
- reduced range of motion
radiographic findings for oA
joint space narrowing
marginal osteophytes
subchondral bone sclerosis (thickening of the joint under cartilage)
abnormal alignment of joint
USUALLY only in advanced disease
lab findings for OA
ESR <20 mm/h
usually significant inflammation = >20
when is diagnosis not required
if ≥45yo
if activity related joint pain (in one or few joints)
morning stiff ≤30min
when should additional testing be done
younger individuals
presence of atypical s/sx
- hx of recent trauma
- rapidly worsening symptoms or deformity
- concerns of infection or malignancy = weight loss, fever…
what are the 1st line non phx treatment recommendations for OA
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…
what are the 1st line phx treatment recommendations for oa
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
what kind of exercises can be done for OA
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
dosing for NSAIDs
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 (nurofen = ibuprofen 200mg 2 tabS TDS)
ketoprofen 50mg q6 max 300
naproxen 250-500 q12, mx 1250 acute, 1000 chronic
naproxen sodium 275-550mg q12, max 1100 chronic, 1375 acute (alleve = naproxen sodium 220mg 1 tab BD)
celecoxib 200mg OD, max 400
etoricoxib 30-60mg OD, max 120 acute 60 chronic
risk factors for GI toxicity of NSAIDs and management
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
suspected NSAID induced GI complications
fatigue sx
severe dyspepsia
signs of gi bleeding
unexplained blood loss, anemia
iron deficiency
= refer immediately…
cvs dosing limitations for nsaids
mi stroke vascular death
celecoxib use at doses <400mg/day
diclofenac <150mg/day
for patients with established CVD: CHF, IHD, uncontrolled hypertension
renal toxicity concerns for NSAIDs
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…
allergic/pseudoallerigc considerations
can use coxibs if not serious
if serious then avoid all
avoid in asthma (caution with cox2 selective)
what are the possible pseudoallergic reactions
bronchospasm
urticaria
angioedema
anaphylaxis…
hematological considerations for NSAIDs
inhibits platelet function, stop 3 days before surgery
(1 week for aspirin)
avoid in haemophilia
cns complaints for nsaids
some complaints of drowsiness dizziness headaches tinnitus..
pregnancy considerations for nsaids
avoid in pregnancy, especially 3rd trimester…
what tramadol dose to give and when
mod to severe pain
25-50mg TDS
max 400mg per day
only when contraindicated to NSAIDs
dose of IA GC, how long and when
mod to severe pain
contra/failure of NSAIDs
DO NOT USE ROUTINELY, short term 4-6 weeks only
contraindications for IA GC
periarticular infection
sepsis arthritis
periarticular fracture
joint instability
juxta-articular osteoporosis
dosing for IA GC
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
duloxetine considerations
mod-severe if contra or failure of NSAIDs
possibly used w concomitant depression?
however consider the SNRI side effects
topical capsaicin moa?
initial enhanced stimulation of TRPV1 expressing cutaneous nociceptors = painful sensations follwoed by pain relief mediated by a reduction in TRPV1 expressing nociceptive endings
considerations for topical capsaicin including side effects
efficacy unknown
do not use for more than 5 days if patch
may cause burning, erythema, pain…
When to consider surgery
total joint arthroplasty
if
QOL substantially affected
non surgical treatment not effective
contraindications for TJA
ACTIVE INFECTION = check ESR, CRP, joint aspiration, MRI
chronic lower extremity ischamia
skeletal immaturity
INDOMETHACIN considerations
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)
which nsaids are associated with skin reactions
oxicam nsaids (meloxicam, piroxicam)
sulindac,
diflunisal
