OA Flashcards
joints primarily affected
hands, hips, knees
primary OA
idiopathic
secondary OA
due to somethign
protective features of the joint
synovial fluid reduces friction
ligaments and tendons allows for the right tension
bone - shock absorbing
cartilage - thin coating at two opposing ends of bones
general pathophys
complex interaction of may extra and intracellular molecules
bone turnover favors cartilage destruction
risk factors for osteo
ethnicity age gender (men at first then women) bone density nutritional joint injury obesity occupation joint biomechanics muscle weakness
clinical diagnosis
> 45
activity related joint pain
morning stiffness <30min
lab tests only to rule out other causes
symptoms **
stiffnes in morning or after periods of inactivity <30min
localized to affected joint
pain worse with activity or prolonged use
signs ***
often unilateral
joints not tender or inflamed
joint instability
no systemic symptoms
cause of pain
not due to destruction of catilage
from activation of nociceptive nerve endings within the joint by mechanical and chemical irritants
may be due to distension of the synovial capsule
what do we see in xrays
narrowing of joint space
osteophytes
bone cysts
when do we do xrays
not needed for intial usual presentation of OA or follow up
symptoms dont correlate with image abnormalities
nodes in OA
heberden
bouchard
reasons for further evaluation in patient complaining of new onset joint pain
duration > 1week recent significant trauma fever, infection, rash injury muscle weakness burning, numbness, tingling inflammation or stiffness >1hr
goals of therapy***
relieve or eliminate pain
improve/restore joint function adn mobility
improve muscel strength to protect the structures
prevent and reduce damage to the joint structures
max quality of life
educate the patient to promote adherence
algorithm for treatment
- non pharm, topical analgesics
- acetaminophen
- asses GI and CV risks and choose a nsaid
low GI and CV risk
low dose non selective nsaid
low GI and high CV
naproxen + gastroprotection
high GI high CV
naproxen + gastroprotection +
low dose celecoxib ?
avoid
high GI low CV
low dose NSAID + gsatroprotection or low dose celecoxib
high GI and CV factors, previous ulcers, use of oral corticosteroids or anticoagulants (including low dose ASA)
low dose celecoxib + gastroprotection
options for hand OA
topical capsaicin or nsaids
oral nsaids
options for knee OA
acetaminophen
topical and oral nsaids
intraarticular corticosteroids injections
not topical capsaicin
options for hip OA
acetaminophen first line
intrarticular corticosteroid injections
oral nsaid
not topical capsaicin
non pharms
strength training and aerobic exercise weight loss joint protection supportive footwear assistive devices social support heat and cold therapy massage surgery
acetaminophen dosing
325-100mg every 4-6 hrs for 2 weeks
max 4g/day
acetaminophen role
first line
acetaminophen efficacy
same as nsaids in mild non inflammatory
less effective in advanced
safety of acetaminophen
max 3.2g/day in elderly
avoid in >3 drinks per day
warfarin
hepatotoxicity
capsaicin dosin
apply tid-qid for 3-4 weeks
capsaicin role
first line in hand
capsaicin onset
2 weeks to take effect
safety of capsaicin
tingling, burning, redness
topical diclofenac role
first line in hand or knee
safety of topical diclofenac
minimal systemci safety concerns
NSAID role
alternative for hand if cant toleracte skin reactions or inadequate relief
in knee and hip if fail or contraindication to acetaminophen
safety of nsaids
nausea, abd pain, diarrhea
ulcer, GI bleed, kidney disease, hepatitis
what is considered high CV risk
on lose dose ASA
high 10yr CV risk
methylprednisone dosing
10mg per joint, 20-80 for large
max 3 injection/joint/year
IA steroids role
alternative first line for knee and hip when pain control with acteaminophen or nsaids suboptimal
efficacy of IA
superior to placebo in alleviating pain but relatively short duration (4-6 weeks)
safety og IA steroids
inexpensive, safe, effective
hyperglycemia, edema, increase BP, flushing
sodium hyaluronate dosing
injection once or weekly for 3-5week
role of IA hyluronic aicds
not recommended
limited efficacy and serious events
IA hyluronic acid safety
increased pain, joint swelling, stiffness
pseudogout
duloxetine dose
60mg daily
duloxetine role
adjunctive in partial response to first line analgesics
second line in patients with neuropathic pain as well
duloxetine efficacy
as an add on shown effiacy
reduction of pain occurs in 4 weeks
safety of duloxetine
nausea, vomit, constipation
CI in liver disease and severe renal impairment
tramadol dose
25mg AM titrate 25mg to reach 100tid
tramadol role
alternative first line in knee/hip who failed everything else
can add on to acet or nsaid
tramadol efficacy
mod improvement as add on
reduction in pain occurs in 4 weeks
tramadol safety
nausea, vomiting, dizzy, constipation, headache
taper
cox 2 inhibitors gastroprotective effects are negated by
ASA
glucosamine chondroitin efficacy
not shown to improve pain control and function
studies that showed any benefit were short duration
risk factors for UGI event
>65yo use of anticoagulants use of steroids history of PUD high dose NSAID presence of hpylori
bottom line for corticosteroids shots
reduce pain at 6 weeks but then less and less
long term pain relief uncertain but serious events are very rare
adequate trial of duloxetine
if min response at 6 weeks probably wont get a beter one
monitoring
decrease in pain daily pain relief daily hepatotoxicity baseline and annual blood in vomit or stool BP iwithin 1 week of nsaid therapy renal function - edema, scr
