OA Flashcards
OA - PRICMCP?
P: how many joints affected/which joints (WB joints, PIP+DIP+MCP, 1st MTP foot)? Any features of inflammatory arthropathies? (morning stiffness >1h, gelling, pain even at rest, redness/swelling)
R: OA, FH, previous injuries (e.g. RSI/sports), Age, Sex (F>M)
I: none
C: functional limitations, inability to exercise/lose weight, fall
Complications of NSAIDs - HF, bleeding.
M: Non-pharm? (supervised exercise, mobility/stretch exercise, walking aids, weight loss), Pharm (NSAIDs, topical, steroid injections, SSRI), Surgery
C: is patient managing around the house - ADLs?, can patient drive?
P: any planned surgery or injections
OA examinations? (8)
Obesity
Gait - ?Antalgic.
Walking aid
Heberden’s and Bouchards
List joints affected, including MCP of thumb, PIP + DIPs
Features of inflammation: temperature/erythema
Crepitus
Restricted ROM
Fine motor function
What investigations would you ask for to confirm the diagnosis? (4)
Largely clinical but r/o inflammatory arthropathies & infection
XR hands looking for LOSS: loss of joint space, osteophytes, subchondral cysts & sclerosis, soft tissue swelling
MRI - BM lesions: sclerotic but poorly mineralised.
Bloods: normal WCC, CRP, ESR
Joint aspirate: WCC <2,000 (non-inflammatory)
Joint aspirate range of WCC for normal, non-inflammatory, inflammatory, septic/crystalopathies?
Joint fluid aspirate for WCC
<200 is normal
200-2,000 is non-inflammatory (e.g. OA)
2000-20,000 is inflammatory (e.g. RA)
>20,000 is septic or crystal
What is your management for this patient with osteoarthritis?
Goals: manage pain, improve functionality and QOL.
Non-pharmacological
- Exercise:
- individualized program depending on current mobility based on assessment (small-moderate effect, similar to that of NSAIDs/panadol)
- If functional/mobility limitation → water-based exercise regimes
- Exercise should be targeted, aerobic of possible, include stretching + flexibility routines
- Supervised exercises are better for pain reduction
- Mobility aids such as a stick, knee braces and foot orthoses
- Weight loss, as obesity is an important modifiable risk factor, 50% improvement in symptoms with 10% weight reduction
Pharmacological
- NSAIDS first line, efficacy is superior to paracetamol, combine with PPI if concerned - reduces dyspepsia by 66%
- Topical NSAIDS - local drug delivery reduces GI side effects.
- Topical capsaicin can also be used
- Paracetamol no greater than placebo for knee arthritis, lower effect than NSAIDS
- Intra-articular injections (steroids, hyaluronic acids) - provide short-term pain relief (2 weeks) but improves the function
- Remember if given too frequently (>4 monthly) → cartilage/joint damage
- Opioids - alternative for patients who cannot tolerate or be prescribed first-line drugs
- SSRI (superior than placebo)
Surgical
- Joint replacement surgery should be considered for severe clinical disease with inadequate response to conservative treatment.
How would you manage this obese patient with severe OA knees? (3)
The priority should be weight loss, as loss of 10% weight can result in up to 50% reduction in pain. Challenge is limited ET in the context of severe OA.
Goals: 10% weight loss over 6-12 months
My approach would be:
- Weight loss by reducing the intake & diet changes, e.g. Mediterranean diet, Optifast diet / VLED
- Speak to PT to organise a supervised/individual exercise program - with emphasis on low-impact exercises such as water-based exercise, targeted muscle exercises. ~30 minutes moderate intensity 5 times per week.
- Screen & treat secondary causes e.g. endocrinopathies, depression
What would you advise this patient with hip arthritis and a history of IHD about the use of NSAIDs?
Highlight NSAIDs are associated with increased risk of CV events - MI, stroke, HF
COX2 inhibition → reduced PGI2 → no inhibition of thromboxane A2 → pro-thrombogenic
If must be used: lowest dose, shortest duration possible, alternative agents if possible.
Preferred agents (no GI risk factors): Naproxen or Ibuprofen
Those with GI bleeding: Celecoxib is preferred.
