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The Patient > Joints > Flashcards

Joints Flashcards

1
Q

How many osteoporosis related fractures are there per year in the UK?

A

230,000, costing 1.8b

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2
Q

What is the incidence of complications of hip fractures?

A

associated with prolonged hospital stays, 20% die within 6 months due to HAI/VTE etc

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3
Q

How many people does osteoporosis affect ?

A

1 in 2 women over 50

1 in 5 men over 50

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4
Q

What is the thick/outer shell of the bone called?

A

cortex

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5
Q

What is the meshwork inside the bone called?

A

trabecular bone

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6
Q

What do osteoblasts do?

A

Build new bone

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7
Q

What do osteoclasts do?

A

Break down old bone (resorption)

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8
Q

What causes osteoporosis?

A

increased osteoclast activity, decreased osteoblast activity, low peak bone mass

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9
Q

What is the WHO definition of osteoporosis?

A

a generalized skeletal disorder of low bone mass (thinning of the bone) and deterioration in its architecture, causing susceptibility to fracture.

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10
Q

How long does it usually take for bone to be remodelled?

A

100 days

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11
Q

What factors influence bone turnover?

A

hormones (oestrogen, testosterone), cytokines, prostaglandins

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12
Q

What are the signs/symptoms of osteoporosis?

A
  • fracture (usually first presentation)
  • reduced bone density on DXA scan
  • pain, reduced mobility
  • kyphosis (in vertebral fractures)
  • reduction in height
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13
Q

What problems can vertebral fractures cause?

A
  • 10-20% reduction in height
  • indigestion, neck weakness, back pain, loss of mobility

often underdiagnosed

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14
Q

What is the average age for reaching [peak bone mass?

A

25

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15
Q

After what age does bone mass decrease, and by how much?

A

approx 40, 0.5-1% per year

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16
Q

Why do women have accelerated bone loss?

A

oestrogen has protective effects, which is lost after menopause

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17
Q

What and who are DXA scans used for?

A

measure bone density at hip/lower spine to get a T score

used for high risk patients or those with established OP

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18
Q

What T score is the threshold for osteoporosis?

A
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19
Q

What are risk factors for osteoporosis?

A

Hx of fracture / in 1st degree relative
Smoking, alcohol
Low body weight
Female, Oestrogen deficiency
Corticosteroid use- prednisolone ≥ 7.5mg daily for 3/12 or more
White race
Increase age
Low calcium intake
Lack of exercise
Recurrent falls, Dementia, Impaired eyesight
Poor health/ frailty- especially RA, renal disease, liver disease, IBD

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20
Q

What lifestyle changes can be made to help prevent osteoporosis?

A

adequate calcium and vit D
weight bearing exercise
reduce alcohol and smoking
reduce risk of falls, esp in elderly

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21
Q

What medications can be used to manage osteoporosis?

A

Calcium, vitamin D, calcitriol, HRT
SERMS, bisphosphates, calcitonin
strontium, PTH, denosumab

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22
Q

Incidence of osteoarthritis?

A

2% overall, 12% of over 65s

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23
Q

When is the most common onset of osteoarthritis?

A

40-60

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24
Q

Who is more at risk of osteoarthritis?

A

women, obese people

25
Q

What are the clinical features of osteoarthritis?

A
  • joint pain, worsened on movement and at end of day
  • possible swelling
  • most common in knee, hands, lumbar and cervical spine
  • early morning stiffness up to 30 mins
26
Q

What is the pathogenesis of osteoarthritis?

A
  • cartilage roughens and thins
  • thickening of underlying bone
  • formation of osteophytes
  • thickening/inflammation of synovium
  • thickening and contraction of ligament
27
Q

What are the goals of osteoarthritis management?

A

reduce pain, improve mobility, minimise joint deformity,

28
Q

What non-pharmacological options are there for osteoarthritis?

A

weight reduction, physiotherapy, exercise plan, heat packs, occupational therapy review, psychological support, surgery

29
Q

What pharmacological options are there for osteoarthritis?

A

simple analgesics, NSAIDs, corticosteroids, chondroprotective agents

30
Q

Incidence of rheumatoid arthritis?

A

1-3% of population, 3:1 female to male

onset most common 30-50s

31
Q

What are the clinical features of rheumatoid arthritis?

A
  • slow, progressive, symmetrical polyarthritis
  • pain & stiffness in small joints of hands and feet
  • early morning stiffness
32
Q

What joints does rheumatoid arthritis involve?

A

wrists, shoulders, elbows, knees, ankles

33
Q

What are some extra-articular symptoms of rheumatoid arthritis?

A

Sjorgens syndrome, vasculitis, neuropathy, subcutaneous nodules, lymphadenopathy, cardiovascular disease, depression, respiratory disease

34
Q

What are the outcomes for people with rheumatoid arthritis?

A

75% have some joint pain, swelling and flare ups
20% will always have mild RA
5% will develop severe extensive disability

35
Q

What is the pathogenesis of rheumatoid arthritis?

A
  • lymphocytes infiltrate synovial membrane, causing inflammation and thickening
  • formation of pannus over cartilage causes erosion into bone
  • eventual degeneration of cartilage and joint
36
Q

What are the goals of management of rheumatoid arthritis?

A
  • relief of pain/inflammation
  • prevention of joint damage
  • preservation/improvement of functional ability
  • maintenance of lifestyle
37
Q

What pharmacological options are there for management of rheumatoid arthritis?

A
  • NSAIDs
  • analgesics
  • steroids
  • conventional DMARDs
  • biological DMARDs
38
Q

What is a DMARD?

A

Disease Modifying Anti-Rheumatic Drug

39
Q

Difference between osteoarthritis and rheumatoid arthritis: joint involvement?

A

OA: often limited to one joint
RA: symmetrical and many joints involved

40
Q

Difference between osteoarthritis and rheumatoid arthritis: effect of movement?

A

OA: pain worsens on movement and as day progresses
RA: improves with movement

41
Q

Difference between osteoarthritis and rheumatoid arthritis: stiffness?

A

OA: wears off over the day
RA: worsens over the day

42
Q

Difference between osteoarthritis and rheumatoid arthritis: swelling?

A

OA: may be swelling
RA: usually swelling

43
Q

First recommendations for adults newly diagnosed with rheumatoid arthritis?

A

offer first line conventional DMARD - methotrexate, leflunomide or sulfasalazine
- consider hydroxychloroquinine as alternative for mild diseae

bridging therapy of oral, IM or IA steroid

NSAIDs/analgesics max dose

44
Q

Step up therapy for rheumatoid arthritis if initial treatment is not effective?

A

additional cDMARDs

45
Q

Treatment options if cDMARDs are not effective?

A

DAS28 score of greater than 5.1

Biolgoic DMARDs - Sarilumab, with methotrexate (can also be used as monotherapy)

46
Q

What is the DAS?

A

Disease activity score - greater than 5.1 = severe

47
Q

Advantages of biologic DMARDs over conventional ones?

A
  • can be combined with other drugs
  • quicker response to treatment
  • better tolerated
  • may reverse joint damage
48
Q

Disadvantages of biologic DMARDs over conventional ones?

A
  • cost
  • infection risks
  • self administration, may be an issue
49
Q

What screening treatments must be done before starting treatment with biologic DMARDs?

A
  • TB, HIV, Hep A, Hep B
  • cancer history
  • recent travel abroad
  • Chest xray
  • History of heart disease
  • exclude pregnancy
50
Q

Important counselling points for hydroxychloroquinine

A
  • how it will help symptoms
  • up to 3 months to work
  • dose
  • GI side effects - mild
  • if rash to stop immediately
  • eye checks needed
51
Q

Important counselling points for methotrexate?

A
  • how it will help symptoms
  • up to 3 months to work
  • dosing once weekly
  • folic acid and role
  • side effects: nausea, mouth ulcers, hair loss (rare), increased infection risk, liver toxicity (limit alcohol)
  • get vaccinations but avoid live ones
  • don’t get pregnant
  • interactions: aspirin, trimethoprim, septrin (co-trimoxazole)
  • regular blood tests
52
Q

Important counselling points for sulfasalzine?

A
  • how it will help symptoms
  • up to 3 months to work
  • indigestion
  • rash - stop immediately
  • may discolour urine and contact lenses
  • pregnancy - it’s safe
  • regular blood tests
  • vaccinations but avoid live ones
53
Q

Counselling points for alendronate?

A
  • role in helping bone health
  • once a week
  • take at least 30 mins before breakfast
  • full glass of water
  • stay upright (dont lie down) for at least 30 mins
  • see GP if throat discomfort or indigestion
54
Q

What alternatives are there for osteoporosis patients if alendronate is not effective or tolerated?

A
  • other oral bisphosphonate, : risedronate, ibandronate
  • yearly infusion of risedronate, esp if GI effects with oral
  • Denosumab is next option- sc injection twice a year, inhibits RANK ligand protein which is involved in stimulating osteoclasts activity
55
Q

Lifestyle advice to patients with osteoporosis?

A

Calcium rich diet/supplements of ca and vit d3, weight bearing exercise

56
Q

Mechanism of rituximab?

A

inhibits B cells

57
Q

Mechanism of tocilizumab?

A

inhibits interleukin

58
Q

Mechanism of abatacept?

A

inhibits T cells

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