Intra-articular Medication

Question 1

What does a healthy joint consist of?

Answer 1

1) synovial membrane
2) joint capsule
3) Cartilage
4) subchondral bone

Question 2

What is they synovial membrane composed of?

Answer 2

Two layers to the synovial membrane

1)Subintimal (blood supply and innervation)

2) intimal (synoviocytes)
- macrophage type A
- fibroblasts type B

Question 3

What are the three types of synoviocytes?

In what layer of the synovial membrane are they found?

Answer 3

Type A- Phagocyctes (Macrophages)

Type B- Production cells (fibroblasts: HA, Aggrecan, Collagen, Cytokines, Eicosanoids, Proteases)

Type C

Question 4

What is Aggrecan?

Answer 4

• Type C synoviocyte
• one of the largest proteoglycans in the joint
• can bind up to 50x its weight in water
• part of the intimal synovial layer

Question 5

What is subchondral bone?

Answer 5

• shock absorber
• more deformable than cortical bone
• sclerosis may contribute to OA progression

Question 6

What type of cartilage is used to define the health of a joint?

Answer 6

Articular cartilage

Question 7

What is articular cartilage composed of?

Answer 7

1) 80% water

2) OG, HA, Collagens

Question 8

What are proteoglycans composed of?

Answer 8

Protein + glycosaminoglycan (GAG) components

Question 9

What is the relationship between Aggrecan and Hyaluronic Acid?

Answer 9

• forms aggregates with HA

- protects collagens from damage

Question 10

What is hyaluronic acid?

Answer 10

The Backbone of the cartilaginous matrix

Question 11

How do proteoglycans/Glycosaminoglycans bind to HA filament?

Answer 11

They bind via a protein link

Question 12

What is the importance between the relationship between HA and Proteoglycans/Glycosaminoglycans?

Answer 12

Creates a polarized charge —> providing a sponge like shock absorbing effect!

Question 13

What are the clinical parameters of OA in the joint?

Answer 13

1) effusion
2) decreased viscosity of synovial fluid (watery)
3) Increased TP
4) Gross cartilage changes

Question 14

What are some gross cartilage changes associated with osteoarthritis?

Answer 14

Diagnostic arthroscopy

• Yellow
• Fibrillated (mild osteoarthritis)
• Dull
• ulcerated / Pitted

Question 15

What is effusion?

Answer 15

Visible distention of the joint space

Question 16

What are some changes in Subchondral bone during joint disease?

Answer 16

1) sclerosis (strengthens bone), brittle
2) Osteophyte formation ( bone covered in hyaline/fibrocartilage
3) Enthesiophyte formation (soft tissue attachment)

Question 17

What causes decreased range of motion / pain in the synovial membrane/ joint capusule during disease?

Answer 17

1) thickening with chronic inflammation
2) hypertrophy of synovial lining
3) Fibrosis of subintima

Question 18

What are some clinical signs of OA?

Answer 18

1) lameness (Slowly progressive)
2) joint pain
3) decreased range of motion
4) joint effusion

** can be present with/without radiographic changes!

Question 19

What are the goals of treatment for Osteoarthritis?

Answer 19

You cannot stop osteoarthritis!!!

1) reduce inflammation
2) slow progression of degeneration
3) reduce pain
4) restore synovial fluid to normal

Question 20

What are the options to manage Osteoarthritis?

Answer 20

1) chondroprotectives
2) corticosteroids
3) NSAIDs
4) blood based products
5) cellbased treatments

Question 21

List the chondroprotective agents!

Answer 21

1) Hyaluronic Acid (HA)
2) Polysulfated glycosaminoglycans (PSGAGs)
3) Proteoglycans (PG)
4) Pentosan gold plus halo
5) corticosteroids- TRIAMCINOLONE

Question 22

What are chondroprotectives?

Answer 22

Used to protect articular cartilage and cartilagenous matrix

Question 23

What is hyaluronic Acid?

Answer 23

Long unbranched non sulfated GAG

Question 24

Where does HA come from?

Answer 24

Type B synoviocytes, chondrocytes

Question 25

What does Hyaluronic Acid (HA/ Sodium hyaluronate/ hyaluronan) do?

Answer 25

1) provides viscoelasticity, boundary lubrication
2) modulates chemotactic response
3) scavenges free radicals
4) increase production of endogenous HA
5) decreases degradation of Aggrecans

Question 26

What are the three main uses for HA?

Answer 26

1) chondroprotectivew (IA)
2) Analgesic (IA)
3) Reduces cartilage fibirillation (IA)

Question 27

How much and how often should HA be administered to be effective?

Answer 27

• 20mg/joint for improved lameness
• should be administered 1x weekly for 3 weeks
• IA at site most efficacious

Question 28

Hyaluronate is usually used in combination with what?

Answer 28

corticosteroid (TRIAMCINOLONE)

*chondroprotective effect of both the HA and TA with potent antiinflammatory effect of TA

Question 29

What is the common name for Polysulfated Glycosaminoglycans?

Answer 29

ADEQUAN

Question 30

What is PSGAG indicated for?

Answer 30

MOA unknown

1) inhibits degradative enzymes
2) counteracts deleterious effects of IL-1
3) reduction of synovial effusion***

Additionally:

• upregulates GAGs and collagen synthesis
• decrease in inflammatory mediators (PGE2)
• improves synovial membrane

Question 31

What are the draw backs of Adequan?

Answer 31

1) immuno-compromises the joint (reduce the number of bacteria necessary to cause septic arthritis)
* Must use in combo with Amikacin to eliminate this effect

Question 32

What should you never combine ADEQUAN with?

Answer 32

Never combine Adequan with a steroid

Question 33

T/F: Levels required to reduce PGE2 achieved with IA dose only!

Answer 33

TRUE

Question 34

When should HA be used over PSGAG (adequan)?

Answer 34

1) early stage OA

2) HA greater effect on articular cartilage fibrillation

Question 35

What Should not be used in the joints and why?

Answer 35

DEPO
-Methylprednisolone acetate

*deleterious effects on articular cartilage at therapeutic levels