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OU Geriatrics Spring 2018 > Musculoskeletal Disorders in the Elderly > Flashcards

Musculoskeletal Disorders in the Elderly Flashcards

1
Q

Rheumatoid Arthritis in the Elderly

A

– > 50% RF negative
– “Milder” disease
– Fewer joints and large joints more predominant
– Abrupt onset
– Morning stiffness is greater in the elderly

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2
Q

DMARD Considerations in the Elderly: What are the drug options?

A
  • Methotrexate
  • Cyclosporine
  • Cyclophosphamide
  • Sulfasalazine
  • Azathioprine
  • Hydroxychloroquine
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3
Q

DMARD Considerations in the Elderly: Methotrexate

A
  • decreased elimination associated with age related decline in renal function
  • increased ADRs as a result
  • Folic acid supplement is especially important in the elderly to minimize side effects
  • Weekly total doses should never exceed 20 mg
  • MTX 7.5 mg weekly with 5 mg folic acid weekly
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4
Q

DMARD Considerations in the Elderly: Cyclosporine

A

decreased elimination

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5
Q

DMARD Considerations in the Elderly: Cyclophosphamide

A

Overall incidence of infectious and noninfectious complications is not higher in the elderly but mortality from these side effects is increased

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6
Q

DMARD Considerations in the Elderly: Sulfasalazine

A
  • Older patients should be prescribed enteric coated tablets as they are more prone to GI side effects.
  • Elimination half-life is greater.
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7
Q

DMARD Considerations in the Elderly: Azathioprine

A

No age related difference in efficacy or tolerability

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8
Q

DMARD Considerations in the Elderly: Hydroxychloroquine

A
  • Decrease dose in severe renal impairment.

- Elderly are more prone to retinopathy.

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9
Q

Biologic DMARDs in the Elderly: What are the drug options?

A
  • Leflunomide (Arava*)
  • Etanercept (Enbrel*)
  • Infliximab (Remicade*)
  • Adalimumab (Humira*)
  • Anakinra (Kineret*)
  • Abatacept (Orencia*)
  • Tofacitinib (Xeljanz*)
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10
Q

Using Biologic DMARDs in the Elderly

A

Due to risk of infections and/or malignancies (esp. with TNF antagonists and abatacept) older people may be predisposed to an increased risk of these effects

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11
Q

Leflunomide (Arava*)

A

inhibits pyrimidine synthesis – anti-inflammatory effect

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12
Q

Etanercept (Enbrel*)

A

TNF Antagonist

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13
Q

Infliximab (Remicade*)

A

TNF Antagonist

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14
Q

Aadalimumab (Humira*)

A

TNF Antagonist

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15
Q

Anakinra (Kineret*)

A

IL-1 anatagonist

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16
Q

Abatacept (Orencia*)

A

Selective T-cell costimulation blocker

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17
Q

Tofacitinib (Xeljanz*)

A

JAK inhibitor

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18
Q

NSAIDs in the Elderly with RA

A

– Increased risk of GI ulceration and bleed in the elderly.

– Due to prostaglandin inhibition greater likelihood of salt and water retention and thus worsening of CHF or HTN.

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19
Q

Steroids in the Elderly with RA

A

– Use low doses: Prednisone ≤ 10 mg per day and taper over 3 months
– Increased risk of osteoporosis and due to mineralocorticoid effects may worsen HTN or CHF
– Cataracts, glucose intolerance

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20
Q

What happens when you use NSAIDs and steroids together?

A

additive GI risks

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21
Q

Epidemiology of osteoarthritis (OA) in the elderly

A
  • 12% of adults have symptomatic OA
  • Prevalence rises sharply with advancing age
  • After age 75, > 80% of people have OA pathology
  • After age 65, female:male ratio of knee OA ranges from 1.5:1 to 2:1
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22
Q

Pathophysiology of Osteoarthritis

A
  • Characterized by loss of articular cartilage in synovial joint: Exposed bone thickens and is remodeled, Osteophytes form
  • These changes along with thickening of joint capsule, weakening muscles and chronic synovitis limit movement
  • Loss of cartilage is a two step process: Mechanical wear, Abnormal enzyme activity
  • Imbalance between cartilage synthesis and degradation resulting in loss of cartilage, eburnation (thinning of cartilage) and pain
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23
Q

Describe a joint with mild Osteoarthritis

A
  • osteophytes “spurs”
  • mildly thickened inflamed synovium
  • thickened, stretched capsule
  • roughened thinning cartilage
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24
Q

Describe a joint with severe Osteoarthritis

A
  • thickened, crunched-up bone with no covering cartilage
  • inflamed synovium
  • tight, thickened capsule
  • light remaining cartilage
  • bone deformity
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25
Q

Risk Factors for Osteoarthritis

A
  • Aging
  • Obesity
  • Quadriceps muscle weakness
  • Joint overuse/injury
  • Genetic susceptibility
  • Developmental abnormalities
26
Q

Goals of Osteoarthritis Therapy

A
  • Relieve pain / inflammation
  • Enhance QOL and functional independence
  • Retard disease progression
  • Control comorbidity
  • Minimize risks of therapy
27
Q

Pharmacological Management of Osteoarthritis

A 
• Cornerstone 
- Oral analgesics 
- Topical NSAIDs and capsaicin 
- Intra-articular 
corticosteroids 
• Other 
- MSM: Methylsulfonylmethane 
- Glucosamine / Chondroitin
28
Q

Intra-articular corticosteroids

A
  • benefit only for a short period of time
  • cannot inject a particular join more than 3 times with a steroid before being concerned about effects of that steroid on that joint and bone
29
Q

Pharmacological Management of Osteoarthritis: APAP

A

• Analgesic with some anti-inflammatory effect
• Dose: Up to 3 grams per day
• Toxicity:
- Hepatoxicity: Dose and duration related, Pre-existing liver disease and/or concomitant chronic alcohol use increases risk
- Renal: Rare, > 365 doses/year – RR = 2.1 (ESRD)

30
Q

Pharmacological Management of Osteoarthritis: NSAIDs

A
  • Aspirin and Non-acetylated salicylates (Salsalate, Diflunisal, Choline salicylate)
  • Antipyretics, analgesic, antiinflammatory
  • Toxicity - GI
  • Acid / base disorders
  • None are more effective than aspirin
  • Side-effect profile, kinetics and cost determine preference of one agent over another
31
Q

Kinetics of NSAIDs

A
  • Kinetic considerations: First order to zero order
  • Poor correlation between serum levels and analgesic effects
  • Piroxicam (Feldene), meloxicam (Mobic) - qd dosing
  • Naproxen (Naprosyn), sulindac (Clinoril), celecoxib (Celebrex*), - bid dosing
  • Ketoprofen (Orudis) and naproxen (Naprosyn) are highly protein bound - risk of drug interactions
32
Q

Recommendations for NSAID Monitoring

A

• Baseline
– CBC and differential, platelet count, creatinine, ALT, AST
• Systematic review
– Dark/black stool, dyspepsia, N/V, abdominal pain, edema, shortness of breath
– CBC, LFTs, creatinine
– NSAID induced nephropathy

33
Q

Toxicities of NSAIDs

A
  • Dyspepsia > 10%
  • Gastric or duodenal ulceration: 1 - 10%
  • Gastrointestinal bleeding: 1- 2%
  • Renal toxicity: 5% (Sodium and water retention, Analgesic nephropathy, Interstitial nephritis)
  • CNS < 1% (Aseptic Meningitis)
  • Cardovascular: Increased risk of thromboembolic events with COX-2 selective agents, (rofecoxib are valdecoxib are now off the market)
34
Q

NSAID Toxicities of Importance in the Elderly

A
  • Risk of serious gastrointestinal toxicity is 2.5 to 5.5 times greater in the elderly
  • Complications of salt and water retention can worsen hypertension and CHF
35
Q

Relative GI Toxicity of NSAIDs

A 
• Dyspepsia, diarrhea, abdominal pain 
– 25 to 28 % with COX-2 Inhibitor 
– 31% with Non-specific NSAIDS
• Ulceration, bleeding, perforation 
– Celecoxib (Celebrex*) vs. Other NSAIDs 
– 12 month: 0.4% vs. 1.27%
36
Q

Risk Factors for Serious Upper GI Complications Associated with NSAIDs

A
  • Older age
  • Hx of PUD, upper GI bleeding
  • Arthritis related disability
  • High-dose NSAID or multiple NSAID
  • Concurrent steroid use
  • Prior GI side effects
37
Q

Recommendations for Decreasing Risk of NSAID Toxicity: Dyspepsia

A
  • Take dose with at least 8 ounces of water

* Take with food or antacids

38
Q

Recommendations for Decreasing Risk of NSAID Toxicity: Reduction ulceration and bleeding risk

A

In patients with history of PUD or GI bleeding or complications from NSAIDs
– Co-administration of misoprostol or a PPI
– Use minimally effective doses, monitor duration of use (No more than 10 consecutive days)
– Cox-2 inhibitor (?)

39
Q

Recommendations for Decreasing Risk of NSAID Toxicity: Other CV Risk

A

– sulindac (Clinoril*) appears to have least effect on renal blood flow
– Monitor use, avoid prolonged use

40
Q

Pharmacological Management of Osteoarthritis: Glucosamine / Chondroitin

A
  • Remains a mixed message regarding effects on pain, functionality and disease progression
  • Purity of preparations appears to be important
  • Results of a NIH sponsored multi-center long term trial suggested only modest benefit in patients with severe OA of the knee
  • Safe
  • Can take a while to take effect
  • Very modest effects
41
Q

Principles of Managing Chronic Pain

A

• Break the pain cycle
• Monitor for effectiveness of analgesic regimen
– Measure degree of pain relief using a visual analog scale
– Measure duration of relief
• Educate about realistic expectation of analgesics

42
Q

Non-Pharmacological Management of Osteoarthritis

A
  • Weight reduction
  • Education
  • Assistive devices/orthotics
  • Thermal modalities
  • Hydrotherapy
  • Magnetic therapy
  • Muscle strengthening and ROM exercises
  • Social support
43
Q

Other Therapies for the Management of Osteoarthritis

A
  • Hyaluronic Acid injections (knee)

- Surgery (joint replacement therapy)

44
Q

What is the concern with join replacement therapy?

A

don’t know how long the joints hold up

45
Q

What are the different types of gout?

A
  • Acute gouty arthritis
  • Uric acid nephrolithiasis
  • Gouty nephropathy
  • Tophaceous gout
46
Q

Acute gouty arthritis

A

Intense pain, erythema, warmth, swelling, fever

47
Q

Pharmacotherapy of Acute Gouty Arthritis: What are the durgs?

A
  • NSAIDs

- Corticosteroids

48
Q

Pharmacotherapy of Acute Gouty Arthritis: NSAIDs

A
  • Indomethacin
  • Naproxen
  • Sulindac
  • Ibuprofen
  • Colchicine
49
Q

Indomethacin

A

75 mg initially followed by 50mg every 6 hours for 2 days, then 50 mg every 8 hours for 1 to 2 days. May be more problematic in the elderly

50
Q

Naproxen

A

500 mg BID

51
Q

Colchicine

A

– Oral (Colcrys, Mitigare): 1.2 mg initially followed by 0.6 mg in 1 hour
– Authorized generic now available
– Delayed onset and GI toxicity limit its usefulness
– Older people more likely to experience GI side effects and bone marrow suppression: need to use lower doses or possibly avoid especially if CrCl < 30 ml/min.
– Cost is an issue with all products.

52
Q

Pharmacotherapy of Acute Gouty Arthritis: Corticosteroids

A

– Intrarticular triamcinolone - 20 to 40 mg

– Oral prednisone - 30 to 60 mg/day for 3 to 5 days then taper over 10 to 14 days (along with colchicine)

53
Q

Prophylactic Therapy for Gout: What are the drugs?

A
  • Uricosuric
  • Xanthine Oxidase Inhibitors
  • Uric Acid Transporter 1 inhibitor
  • Pegloticase (Krystexxa*) Urate Oxidase
54
Q

What is the goal uric acid level?

55
Q

Pegloticase (Krystexxa*) Urate Oxidase

A
  • IV q 2 weeks

- for completeness of information; just know there are these out there

56
Q

Prophylactic Therapy for Gout: Uricosuric

A
  • enhances secretion of uric acid at the kidney level

- Probenecid

57
Q

Prophylactic Therapy for Gout: Xanthine Oxidase Inhibitors

A
  • Allopurinol
  • Febuxostat (Uloric*)
  • Co-administer low dose colchicine (?)
58
Q

Prophylactic Therapy for Gout: Uric Acid Transporter 1 inhibitor

A

Lesinurad (Zurampic*)

59
Q

Probenecid

A

do not use if CrCl < 30mL/min

60
Q

Allopurinol

A
  • 300 mg/day

- Reduce dose in renal insufficiency

61
Q

Febuxostat (Uloric*)

A

40 to 80 mg/day

62
Q

Lesinurad (Zurampic*)

A
  • Use with a xanthine oxidase inhibitors

- for completeness of information; just know there are these out there

OU Geriatrics Spring 2018 (9 decks)

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