OA/RA

Question 1

What are the physiological changes that cause OA?

Answer 1

Degenerative changes that occur in cartilage and associated bone. Characterized by destruction and subsequent proliferation of cartilage and bone.

Question 2

How often does this occur?

Average age of onset?

Answer 2

About 85% of people over 75years get this

More common in females than males.

Question 3

Where does OA occur in the body?

Answer 3

Mostly hips and knees but can also occur in the spine, neck and distal interphalangeal joints.

Question 4

What are the classic symptoms of OA?

Answer 4

Assymetrical joint pain
Stiffness when getting up in the morning, usually improves after about 30 minutes
crepitus
no systemic involvement
pain on weight bearing

Question 5

What are the classic symptoms of OA?

Answer 5

Assymetrical joint pain
Stiffness when getting up in the morning, usually improves after about 30 minutes
crepitus
no systemic involvement
pain on weight bearing
muscle atrophy
Herberdens and Bouchards nodes

Question 6

What are the biggest differences in clinical signs between OA and RA?

Answer 6

RA is symmetrical pain
Pannus often present in joints
stiffness does not improve throughout the morning

Question 7

What are the biggest differences in clinical signs between OA and RA?

Answer 7

RA is symmetrical pain
Pannus often present in joints
stiffness does not improve throughout the morning
systemic involvement including malaise, fatigue, musculoskeletal pain, diffuse swelling

Question 8

What are the goals therapy when treating OA?

Answer 8

Relief of pain and discomfort
Maintain function and strength of joint
Prevent deformities and progressive changes

Question 9

What does step 1 of OA therapy include?

Answer 9

Non pharmacologic therapy: wght loss, mild exercise, physical therapy, education, rest, heat/ice

Question 10

Step 2 of OA therapy?

Answer 10

Pharmacologic: Acetominophen 500mg every 4-6 hours MAX of 3g/day. Use for 2-4 weeks.

Question 11

Step 2 of OA therapy?

Answer 11

Pharmacologic: Acetominophen 500mg every 4-6 hours MAX of 3g/day. Use for 2-4 weeks.
Topical analgesics also fall into this category such as bengay, capsacin (Zostrix = takes 2-4wks for results)
When using Acetominophen be cautious of hepatoxicity
Diclofenac gel = Max of 16g
Pennsaid = gel with DMSO as carrier molecule causing garlic smell and taste
3 month Trial will let you know if it works or not.

Question 12

Step 3 of OA therapy?

Answer 12

NSAID therapy: If step 2 can choose from a long list of NSAIDS depending on patients comorbidities and other factors. Whichever one you choose, use the analgesia dosing.

Question 13

Step 3 of OA therapy?

Answer 13

NSAID therapy: If step 2 can choose from a long list of NSAIDS depending on patients comorbidities and other factors. Whichever one you choose, use the analgesia dosing

Question 14

What are the major adverse effects that can occur from NSAID therapy?

Answer 14

GI upset
o GI ulcers
o bleeding
o renal dysfunction
o effects on BP

Question 15

What patients are most at risk for adverse effects from NSAID therapy?

Answer 15

dose dependent
o elderly
o h/o GI bleed
o h/o of PUD
o anticoagulant therapy
o antiplatelet therapy
o glucocorticoids
o patients with CHF, HTN, renal dysfunction, and dehydration are at increased risk of nephrotoxicity

Question 16

What are the monitoring parameters for patients on NSAID therapy?

Answer 16

BP
o symptoms of edema or weight gain
o BUN/SCr
o Hgb/Hct
o signs of dehydration

Question 17

What is an example of a COX 2 inhibitor that can be used in OA? What is the benefit of this class of medication?

Answer 17

Celebrex

Once daily dosing, decreased risk of GI bleeding

Question 18

What are potential risks of using COX 2 inhibitors for OA?

Answer 18

increased risk of CV disease
o increased costs
o same impact on renal functions and INR

Question 19

When are PPI’s beneficial in OA treatment?

Answer 19

When concerned about GI upset in NSAID therapy can add a PPI and decrease GI toxicity by 50%

Question 20

When are PPI’s beneficial in OA treatment?

Answer 20

When concerned about GI upset in NSAID therapy can add a PPI and decrease GI toxicity by 50%

Question 21

What is step 4 in therapy for OA?

Answer 21

PRN opioid use as needed for short term relief of break through pain.

Question 22

What is the appropriate way to introduce opioids into OA therapy?

Answer 22

Start low and go slow. Use a long acting and slow acting together. Educate patient on adverse effects.

Question 23

What are the potential adverse effects of opioid use?

Answer 23

Nausea, somnolence, constipation and dizziness

Question 24

What opioid can be used in patients at risk for chemical dependence?

Answer 24

Tramadol

Question 25

When are interarticular injections appropriate in OA therapy?

Answer 25

It is a step 4 therapy for patients that cannot tolerate the opioids and/or are not good candidates for surgery.

Question 26

What are the IA injection options?

Answer 26

Corticosteroid Medications =

Question 27

What are the IA injection options?

Answer 27

Corticosteroid Medications = Very painful injection, cannot be done more than every 4-6 months, relief in 7-10 days, repeated injections can cause further break down.
Hyaluronate Injection (Synvisc) = Temperature increases the viscosity, injected every 3-5 wks, max benefit in 8-12 wks.

Question 28

What is step 5 of OA therapy?

Answer 28

Joint replacement

Question 29

What are the IA injection options?

Answer 29

Corticosteroid Medications = Very painful injection, cannot be done more than every 4-6 months, relief in 7-10 days, repeated injections can cause further break down.
Hyaluronate Injection (Synvisc) = Temperature increases the viscosity, injected once a wk for 3-5 wks, max benefit in 8-12 wks.