Mx of MSK disease Flashcards
What are the core non-pharmacological interventions in people with MSK disease?
Patient education - self efficacy and coping strategies
Exercise - strengthening and aerobic conditioning (improves well-being)
Reduce adverse mechanical factors
Local treatments - heat, cold, acupuncture, pulsed electrical stimulation
Invasive procedures - arthroscopic lavage (not recommended)
Surgery
How can mechanical factors be reduced to reduce symptoms?
Weight loss if obese, modification of work/leisure activities
Pacing of activities related to functional ability
Appropriate footwear - shock absorbing
Walking stick (on contralateral side), aids, appliances
Modification of home environment
What types of surgery are used in MSK disease?
joint surgery for persistent severe pain/disability reconstructive surgery (e.g. rup[tured tendons) removal of inflamed synovium to prevent damage
How do corticosteroids act?
inhibit COX-2, cytokines and ILs
increase annexin-1 production, which has anti-inflammatory effects
What are the widespread side effects of corticosteroids?
infection/poor wound healing peptic ulceration acute adrenal insufficiency upon withdrawal cushing's syndrome DM osteoporosis avascular necrosis psychological effects inter-scapular fat pad
What should be prescribed alongside long term corticosteroids?
PPI
vitamin D
bisphosphonates
What are the benefits of intra-articular injections?
can have a diagnostic and therapeutic effect
injections into joints/periarticular structures provide pain relief
How can intra-articular injections be diagnostic?
the preparation often contains local anaesthetic and so if pain resolves within a short period of time, we can reasonably confident that the pain is coming from the structure injected
What are the disadvantages of intra-articular injections?
do not repeat more than 3 in 6 months
there can be systemic absorption and side effects
What are the benefits of physiotherapy in MSK disease?
aerobic training - reduces pain and disability, improves restorative and helps with weight loss
Local strengthening exercises - can reduce pain and disability over compromised joints
What is a DMARD?
disease monitoring anti rheumatic agents
eg methotrexate, sulfasalazine, hydroxychloroquine, penicillamine and gold compounds
When are DMARD drugs used?
initiated as soon as a diagnosis of inflammatory arthritis is reached, they reduce pain score, disability score and RF level
How do DMARDs act?
clinical effect is slow so steroids are used to ‘cover’ the induction phase
What is combination therapy?
two drugs used together generally appear superior to monotherapy.
for example: methotrexate plus hydroxychloroquine for less severe / methotrexate plus for more severe presentations
How is methotrexate given?
once weekly dosing (oral/IM)
folic acid should be taken on the other days
What are the signs of methotrexate toxicity?
bruising
infection
SOB (pulmonary toxicity)
What monitoring takes place for patients on methotrexate?
frequent monitoring FBC, LFT, U&Es are required every 10 weeks once settled on drug
Common side effects of methotrexate?
nausea
headaches
tingling
When is methotrexate not suitable?
pregnancy
males trying to concieve
What is the mode of action of sulfasalazine?
takes around 8 weeks to have a clinical response
What monitoring is needed on sulfasalazine?
FBC, U&E, LFT should be monitored monthly for the first three months
What SEs are common on sulfasalazine?
nausea and dyspepsia rashes blood dyscrasias azoospermia (no sperm in semen) yellow/orange discolouration of urine/contact lenses
What is the mode of action of hydroxychloroquine?
least effective but least toxic
takes 6 weeks for a clinical response
What monitoring is needed for hydroxychloroquine?
baseline visual activity and annual re-check
What are the side effects of hydroxychloroquine?
rash
GI disturbance
Peripheral neuropathy
retinal damage
What biologic is most commonly used?
ant-TNF agents
eg infliximab, etanercept
What are the contraindications to using biologics?
active infection latent TB malignancy pulmonary fibrosis severe heart failure
What are the adverse effects of using biologics?
opportunistic infections
non-melanoma skin cancers
injection site reactions
- patients are vaccinated each year
- CXR required to exclude TB prior to commencing treatment
- advised to present early if any signs of potential infections
- infusion reactions can occur so many are given in hospital initially before becoming self taught
What are the general orthopaedic complications?
wound infection
DVT - occur in 50% of total hip/knee replacements (mainly asymptomatic)
MI - most common cause of death
local neurovascular injury
compartment syndrome
periprosthetic fracture: peri-operative or delayed
complex regional pain syndrome
