Osteoarthritis Flashcards
Topical applications in osteoarthrtis
- Capsaicin, NSAIDs
- Topical NSAIDs have proven short-term efficacy, but here is insufficient information to comment on long-term use (greater then 12 weeks), and they are markedly more expensive than oral NSAIDs
- Topical NSAIDs are recommended over oral NSAIDs for patients older than 75 years
- Topical capsaicin should reduce pain in about 2 weeks
NSAIDs in osteoarthritis
- 1st line for mild osteoarthritis (acetaminophen not recommended by ACR for hand OA
- Acetaminophen more effective than placebo but less effective than NSAIDs
- One NSAID not preferred over another (ibuprofen interferes with aspirin used for CVD prevention
- COX-2 - efficacy profile same as other NSAIDs but fewer reports of GI events and no affect on platelet function
- for pts with hx of GI event a COX-2 or NSAID with PPI is recommended as primary therapy
- for pts with a GI bleed in past 12 months, ACR recommends a COX-2 inhibitor with a PPI
Controlled opioid analgesics in osteoarthritis
- can be useful but should not be used routinely
- patients may respond to therapy but limit use to patients with sever pain that is inadequately controlled with previously mentioned therapies
- likelihood of adverse events similar to that of NSAIDs
- NOT routinely recommended for osteoarthritis because risk and severity of adverse events outweigh their benefit potential
Glucosamine and chondroitin in osteoarthritis
- delayed onset of effect, cannot be used for immediate pain relief
- Trials that evaluate the use of glucosamine (with or without chondroitin) are usually small and of variable quality, resulting in highly heterogeneous conclusions in meta-analysis and systemic review
- NOT routinely recommended by ACR
Tramadol
Non-controlled opioid analgesic
Con Zip, Rybix, Ryzolt, Ultram, Ultram ER
Tramadol STEPS - Safety
- Avoid use in (Rybiz, Ultram, Ultram ER) in any situation where opioids are not indicated, including acute intoxication with alcohol, hypnotics, opioids, or psychotropic drugs.
- Avoid use (Con Zip, Ryzolt) in patients with severe/acute asthma, hypercapnia, or severe respiratory depression in the absence of resuscitative equipment
- Contraindicated within 14 days of monamine oxidase inhibitor therapy
- limit immediate-release dose to 50 mg q12h in patients with cirrhosis
- Cautious use in patients with mild to moderate renal impairment nad avoid extended-release formulations in severe renal impairment (CrCl there is still a chance of misuse, abuse, and diversion
Tramadol STEPS - Toelrability
- CNS depression
- Constipation
- Dizziness
- Dyspepsia
- Flushing
- Headache
- Nausea
- Postural hypotension
- Pruritis
- Somnolence
Tramadol Steps - Efficacy
Provides small degree of pain relief
Tramadol STEPS - Preference (Pearls)
Consider as an alternative in patients who do not receive adequate pain relief from acetaminophen and cannot tolerate or for whom NSAID therapy is contraindicated
Intra-articular Corticosteroids in OA
- may be effective for short term pain relief (less than 4 weeks), but usually with diminishing benefit beyond that time
- joint injections should not be performed more often than every 3 months
- OA symptoms requiring regular use of corticosteroid injections (3 or 4 a year) should be considered for surgical intervention
Intra-articular Hyaluronic Acid in OA
- may be as effective as intra-articular corticosteroids for some patients, but with benefits observed up to 6 months
- benefits over corticosteroids not observed until 4 weeks after injections
- much more costly alternative to intra-articular corticosteroids
- more frequent injections because many regimens require weekly injections for 3-5 consecutive weeks.
Alternative therapies in AS
1) SAMs (S-adenosylmethionine) may decrease and improve functional limitiations in patient with osteoarthritis
2) Avocado/soybean unsaponifiables appear to help reduce pain in patient with OA, bur few trials with questionable supportive bias
3) Devil’s claw (Harpagophytim procumbens) has been associated with pain reduction in osteoarthritis in several low-quality clinical trials
