OA Flashcards
what are the treatment goals for OA?
- relieve pain
- maintain/restore mobility
- manage functional impairment
- improve QOL
what is the 1st line of treatment of OA?
topical NSAIDs
1. oral NSAIDs
2. Tylenol
when is tylenol recommended for OA?
hand, knee, and hip OA
- if patient is not a candidate for NSAIDs
what is the dose of tylenol for OA?
325-650 mg every 4-6 hours scheduled or 1 g 3-4 times daily
- max 4,000 mg daily
- dose adjust in patients with liver disease or chronic alcoholic intake
what are important things to keep in mind when giving tylenol?
- hepatotoxicity
- watch for hidden acetaminophen (cold meds)
- warfarin interacts with chronic doses over 2g/day a day (can increase INR –> more likely to bleed)
when are oral NSAIDs indicated for OA?
hand, knee, hip OA
- if no contraindications (1st line over all other orals)
- risk assessment is necessary
what are the oral NSAIDs?
- Celecoxib* (Celebrex)
- ibuprofen (Advil, Motrin)
- indomethacin (Indocin)
- meloxicam* (Mobic)
- nabumetone*
- naproxen (OTC: Aleve, Rx: Naprosyn)
•NSAIDs with ↑ COX-2 selectivity: ↓ GI risk (though still present); ↑ CV risk; same renal risk
what dose should be used for oral NSAIDs?
lowest effective dose in shortest duration
- Celecoxib: 100 mg BID or 200 mg daily
- Ibuprofen: 400-800 mg Q6-8H (Rx) | 200-400 mg Q4-6H (OTC)
- Meloxicam: 15 mg daily
- Naproxen: 500 mg BID (Naprosyn; Rx) | 200 mg (220 mg naproxen sodium; OTC) Q8-12 H; 1st dose can take 2 tabs (max 3 tabs/24 hours)
what is important to consider when giving oral NSAIDs?
- routine monitoring advised
- adverse GI< CV, and renal effects
- watch for drug interactions
What are the non selective and Cox-2 selective NSAIDS and when are they indicated?
(Irreversible) NON: ASA
*cardioprotective at low doses
*increased risk for GI SE
COX-2 : Celecoxib
*increased risk for CV events
*decreased risk for GI SE
What are the semi selective NSAIDs and when are they indicated?
- Ibuprofen, naproxen (non selective)
*decreased risk for CV events
*Increased risk for GI SE - Indomethacin, Nabumetone
*use with caution in patients at increased CV risks
what are risks of oral NSAIDs for GI events?
- increased risk of potentially fatal GI bleeding
- ulcers
- perforations
what are cardio event risks of oral NSAIDs?
- increased the risk of potentially fatal MI or stroke
*avoid in patients with or at risk of CVD
what are BP risks of oral NSAIDs?
- if controlled: okay (use caution)
- avoid in uncontrolled HTN
what are renal events risks of oral NSAIDs?
- decreased renal clearance
- risk factors: dehydration, nephrotic agents
- avoid or use with caution in proteins with renal failure
if there is a low GI risk and low CV risk, what NSAIDs to use?
any - Celecoxib, or other low GI risk NSAIDs
if there is a high GI risk and high CV risk, what NSAIDs to use?
none - use tylenol
how to monitor NSAIDs for GI risks?
- hemoglobin/hematocrit
- blood in stool
- abdominal pain
- dyspepsia
how to monitor NSAIDs for CV risks?
- blood pressure
- edema
- weight gain
how to monitor NSAIDs for renal risks?
- Scr and BUN
- urine output
when are topical NSAIDs indicated?
- knee OA (prior to oral NSAID = lower systemic absorption), 2. conditionally recommended for hand OA
*NOT for hip OA
what is the drug for topical NSAIDs?
Diclofenac (OTC)
what is the dose of topical NSAIDs?
- Knees: apply 4 g to affected area 4 times daily
- Hands: apply 2 g to affected area 4 times daily
- Maximum dose: 32 grams/day
use the dosing card
what is important to consider when giving topical NSAIDs?
- same warnings as oral NSAIDs, but less systemically absorbed
when is intra-articular corticosteroid injections indicated for OA?
- strongly recommended for knee and hip OA
- conditionally recommended for hand OA
what drugs are used for an intra-articular corticosteroid for OA?
Triamcinolone (Kenalog), methylprednisolone acetate (Depo-Medrol)
what are the side effects of intra-articular corticosteroid for OA?
- pain, swelling, and arthralgia
- increase in blood pressure and blood glucose possible
what is important to consider when giving a intra-articular corticosteroid for OA?
- 3-4 injections per year
- usually lasts 4-8 weeks
when is duloxetine (cymbalta) indicated for OA? (SNRI)
conditionally recommended for hand, knee, and hip OA
What is the maximum dose for duloxetine (cymbalta)
60mg
when is tramadol used for OA?
conditionally recommended for hand, knee, and hip OA
what is the MOA of tramadol?
mu opioid receptor –> blocks pain pathways
if someone has a CrCl less than 30, can a person use tramadol?
yes, but lower the dose
What are the SE of tramadol
- N/V
- Constipation
- Seizures
- Somnolence
- Potention for misuse and death (C-IV BW)
when is capsaicin indicated for OA?
- conditionally recommended for knee OA
- do not use for hand or hip OA
what is the MOA of capsaicin?
decreases substance P
what is important to consider when giving capsaicin?
- isolated from hot peppers
- immediately wash hands
- used regularly
- takes 2-4 weeks of continuous application to get an analgesic effect
what is the treatment guidelines for knee and hip OA?
- acetaminophen
- if C/I –> NSAIDs (topical knee only) or steroids or oral NSAIDs - Used acetaminophen or alternative first line doesn’t work –> opioids, surgery, duloxetine (knee only)
what is the treatment guideline for hand OA?
patient over than 75?
1. topical NSAIDs/tramadol
2. if 1 doesn’t work –> try 2 agents
patient less than 75?
1. oral NSAIDs/topical NSAIDs/capsaicin/tramadol
2. if 1 doesn’t work –> try 2 agents
when is chondroitin recommended for OA?
- for hand OA
- against knee and hip
*look for USP verified mark
do not use what for OA? (Supplements)
glucosamine or intraarticular hyaluronic acid
*risk adverse effects with administration
