Module 15 - OA and RA Flashcards
- Tertiary Prevention: Non Pharm Therapy for OA
- Use first
- Exercise
- low impact aerobic (tai chi !!!)
- balance and strength training
- resistance
- Weight loss
- Physical Therapy
- Acetaminophen for OA
- Inhibits prostaglandin synthesis
- Marginal analgesic effect on OA
- Less toxicity than NSAIDs
- Beware of toxicity from use of multiple acetaminophen products
- Max safe dose = 4g/day
- some say 2-3g
- if etoh intake is increase then 2g/day is rec’d
- NSAID for OA
- Inhibits COX enzymes
- resulting in decreased prostaglandin production
- acts both centrally and peripherally
Hip: CANNOT use topical, only oral
Hand and Knee: CAN use topical or oral
- Topical NSAID for OA
- Less effective than oral
- Rec’d for pts >75yo with hand and knee OA
- Preferred in pts with CV, GI, Kidney disease
- S/E: skin reactions at application site
- Available in cream, gel, patch, solution
- Oral NSAID for OA
- Effective analgesic
- GI Toxicity:
- SE: nausea, dyspepsia, heartburn, abd pain
- GI: bleeding, ulceration, perforation
- Risk factors of GI Toxicity:
- older pts, history of ulcers/GI bleed, antiplatelets, ACs, oral steroids, SSRI, SNRI
- High risk GI patients need to be co-prescribed PPI !!!!!!!!!!
- Weak Opioid Analgesics for OA
Tramadol
- Weak affect on opioid and serotonin receptors
- NOT linked with serious GI, CV, renal complications
- CAN be added to NSAID and tylenol
- Available in IR or ER
- Taper upon discontinuation
** S/E: n/v, lowered seizure threshold, rash, constipation, drowsiness, dizziness
- Other Topicals
Capsaicin
- weakly recommended
- Use daily for up to 2 weeks before benefit
- Compliance poor without full instructions
- Avoid eye contact
- Pain and redness at application site
- Multiple OTC forms and brands
- RA: How to rule out differential Diagnosis of “Septic Joint”
IDK
- RA Labs
ESR
CRP
PLT
all elevated
sometimes C3 and C4
hypergammaglobulins
- RA Treatment
FIRST LINE: Methotrexate
- Non biologics DMARDS are used as monotherapy for low, mod, high disease activity when patients do NOT have poor prognosis
- Anti TNF agents with and without methotrexate use in patients with high disease activity who HAVE poor prognosis
- DMARDs vs NSAIDS
DMARD:
- Slow onset of action
- 6weeks to 6months
- Arrests the progression
- Prevents new formation of deformity
- Used in chronic cases when deformity is exciting
NSAIDS:
opposite
OA Assessment
Pain is often worse at end of day. Pain during the night that causes the patient to awake from sleep can be a sign of a severely arthritic joint. These can be initially managed with acetaminophen or longer acting anti-inflammatories.
Most patients with arthritis have morning stiffness which typically lasts for less than 30 minutes. Thus, the evaluation of function immediately in the morning will reveal function at its worst. The morning stiffness associated with rheumatoid arthritis typically lasts for 45 minutes or longer.
The pain in osteoarthritis typically worsens with activity and improves with rest. Thus, re-evaluation later in the day will provide a complete assessment.
Initial functional limitations caused by osteoarthritis can be improved with activity modification, exercise, weight loss and joint protection. Pharmacological management with acetaminophen can be added early in the course of treatment.
two year history of frequent episodes of pain and morning stiffness in both hands and wrists. She experiences symptomatic relief with ibuprofen but feels that the episodes are becoming more frequent and severe. On exam, joint swelling and several MCP joints on both hands. XRAY shows joint space narrowing of the MCP joints.
in addition to NSAIDs, what is the most appropriate first line long term medication to treat this patient
RA - Methotrexate
Which of the following clinical manifestations is commonly seen in a patient with RA?
symmetric joint swelling associated with warmth, tenderness and pain
HERB is seen in OA
