Osteoarthritis

Question 1

What are the first-line options for pain relief in osteoarthritis? (2)

Answer 1

Paracetamol
Topical NSAIDs (particularly for hand or knee involvement)

Question 2

If treatment with simple analgesia (paracetamol or topical NSAID) is ineffective for the pain of osteoarthritis, what are the next options for pain relief? (3)

Answer 2

Oral NSAID (discontinue topical NSAID)
Weak opioid analgesic (e.g. codeine)
Topical capsaicin 0.025% (particularly for knee or hand involvement)

Question 3

If simple analgesia (paracetamol or topical NSAID) is ineffective pain relief for osteoarthritis and you start a patient on an oral NSAID, which of the simple analgesia would they discontinue?

Answer 3

Topical NSAID use should be discontinued if starting an oral NSAID

Question 4

If a patient taking low-dose aspirin develops osteoarthritis, which pain relief treatment should be avoided if possible?

Answer 4

NSAID

Question 5

What injections are considered as an adjunctive treatment for relief of moderate to severe pain associated with osteoarthritis?

Answer 5

Intra-articular corticosteroid

Question 6

What non-drug measures should be encouraged in patients with osteoarthritis? (3)

Answer 6

Weight reduction (in overweight or obese patients)
Local muscle strengthening exercise
Aerobic exercise

Question 7

Is glucosamine recommended for the treatment of osteoarthritis?

Answer 7

NO

Question 8

Is chondroitin recommended for the treatment of osteoarthritis?

Answer 8

NO

Question 9

Are topical rubefacients recommended for the treatment of osteoarthritis?

Answer 9

NO

Topical rubefacients may contain nicotinate compounds, salicylate compounds, essential oils, and camphor

Question 10

Are intra-articular preparation of hyaluronic acid and its derivatives recommended for osteoarthritis of the knee?

Answer 10

NO but are available

Question 11

Can intra-articular corticosteroid injections be considered for osteoarthritis?

Answer 11

YES

Intra-articular corticosteroid injections can be considered as an adjunctive treatment for relief of moderate to severe pain associated with osteoarthritis.

Question 12

What are the indications for the use of capsaicin? (2)

Answer 12

1. Localised neuropathic pain

2. Symptomatic relief in osteoarthritis

Question 13

What are the indications for the use of codeine phosphate? (4)

Answer 13

Acute diarrhoea
Mild to moderate pain
Short-term treatment of acute moderate pain
Dry or painful cough

Question 14

What effects can be produced when you combine opioids with benzodiazepines?

Answer 14

Additive CNS depressant effects

• sedation
• respiratory depression
• coma
• death

Question 15

Healthcare professionals are advised to discuss with patients that prolonged use of opioids, even at therapeutic doses, may lead to (?) and (?)

Answer 15

dependence

addiction

Question 16

Should you taper or abruptly withdraw an opioid at the end of treatment?

Answer 16

Taper dosage slowly

Taper dosage slowly at the end of treatment to reduce the risk of withdrawal effects associated with abrupt discontinuation (tapering high doses may take weeks or months)

Question 17

What should you consider in a patient on long-term opioid treatment who present with increased pain sensitivity?

Answer 17

Hyperalgesia

Question 18

What is the maximum daily dose of codeine in children aged 12-18 years?

Answer 18

240 mg

Doses may be taken up to 4 times a day at intervals of no less than 6 hours

Question 19

What should the duration of treatment with codeine be limited to in children aged 12-18 years?

Answer 19

3 days

Question 20

Can breastfeeding mothers use codeine?

Answer 20

NO

Question 21

What are the signs and symptoms of morphine toxicity? (8)

Answer 21

Reduced consciousness
Lack of appetite
Somnolence
Constipation
Respiratory depression 
'pin-point' pupils
Nausea
Vomiting

Question 22

Codeine is contraindicated in patients of any age known to be (?) ultra-rapid metabolisers

Answer 22

CYP2D6

Question 23

What are the contraindications for all opioids? (5)

Answer 23

Acute respiratory depression 
Comatose patients
Head injury 
Raised intracranial pressure
Risk of paralytic ileus

Question 24

In addition to the contraindications for all opioids, what are the additional contraindications for codeine phosphate? (6)

Answer 24

1. Acute ulcerative colitis
2. Antibiotic-associated colitis
3. Children < 18 years undergoing removal of tonsils or adenoids for the treatment of obstructive sleep apnoea
4. Conditions where abdominal distension develops
5. Conditions where inhibition of peristalsis should be avoided
6. Known CYP2D6 ultra-rapid metabolisers

Question 25

What are the common side effects of opioids?

Answer 25

1. Arrhythmias
2. Confusion
3. Constipation
4. Dizziness
5. Drowsiness
6. Dry mouth
7. Euphoric mood
8. Hallucination
9. Hyperhidrosis
10. Miosis
11. Nausea + vomiting (more common on initiation)
12. Palpitations
13. Respiratory depression
14. Skin reactions
15. Urinary retention
16. Vertigo
17. Withdrawal syndrome

Question 26

Respiratory depression is a major concern with opioid analgesics and it may be treated by (?) or be reversed by naloxone.

Answer 26

artificial ventilation

Question 27

Respiratory depression is a major concern with opioid analgesics and it may be treated by artificial ventilation or be reversed by (?).

Answer 27

naloxone

Question 28

Glucosamine is a natural substance found in (1?), (2?), and (3?).

Answer 28

1. mucopolysaccharides
2. mucoproteins
3. chitin

Question 29

What are the common side effects of glucosamine? (6)

Answer 29

Constipation 
Diarrhoea
Fatigue
GI discomfort
Headache
Nausea

Question 30

What is the contraindication for the use of glucosamine?

Answer 30

Shellfish allergy

Question 31

What needs to be monitored in patients taking glucosamine? (2)

Answer 31

Blood-glucose concentration (if impaired glucose tolerance)

Cholesterol (if predisposition to cardiovascular disease)