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PHAR255 > Osteoarthritis > Flashcards

Osteoarthritis Flashcards

1
Q

What is arthritis?

A

joint disorder involving one or more joints
-over 100 different forms (OA, RA, psoriatic, septic, etc)

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2
Q

What is osteoarthritis?

A

chronic, progressive disorder characterized by the loss of articular cartilage primarily in hands, knees, hips, and spine
-not simply a degenerative joint disease

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3
Q

What is the most common form of arthritis?

A

osteoarthritis

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4
Q

What is the relationship between osteoarthritis and age?

A

prevalence increases with age
-peak onset is 50-60 yrs

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5
Q

Describe the etiology of osteoarthritis.

A

MOA not completely understood
-primary: no identifiable factor
-secondary: other metabolic factors identified
genetic component likely
joint trauma is a factor
-biochemical and mechanical changes –> loss of functionality –> changes in cartilage, joint capsule, subtracheal bone

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6
Q

Explain the pathogenesis of osteoarthritis.

A

imbalance between cartilage maintenance and destruction
-malfunction of chondrocyte (responsible for cartilage breakdown)
-end result is loss of proteoglycans and water
-formation of osteophytes (bony outgrowths)
role of inflammatory cytokines and MMP

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7
Q

What are the risk factors for osteoarthritis?

A

modifiable:
-obesity
-joint trauma
non-modifiable:
-age
-sex
-genetics
-joint deformity/misalignment

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8
Q

What are the clinical features of osteoarthritis?

A

gradual onset
initial absence of inflammation or joint swelling
mono-articular at first
pain and swelling with activity
no systemic sx
crepitus
tenderness
limited ROM
bony swelling
joint deformity
instability

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9
Q

Describe the pain associated with osteoarthritis.

A

stages:
-1: predictable, sharp pain brought on by activity
-2: becomes more constant; episodes of stiffness
-3: constant dull/ache; chronic stiffness; intense episodes
worse later afternoon/early evening
may have a neuropathic quality

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10
Q

Which joints are commonly affected by osteoarthritis?

A

PIP, DIP, thumb
cervical and lumbar spine
hip, knee, metotarsophalangeal

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11
Q

How is osteoarthritis often diagnosed?

A

often diagnosed without radiography or lab tests
in general, diagnosed if:
-persistent usage-related pain
-age > 45yrs
-little morning stiffness; more evening stiffness

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12
Q

When is additional testing needed for osteoarthritis?

A

younger individuals
atypical signs/sx
weight loss

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13
Q

What is the role of imaging in the diagnosis of osteoarthritis?

A

x-ray can be helpful for diagnostic clarification or monitoring
x-ray does not necessarily correlate with pain

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14
Q

What is the role of laboratory tests in the diagnosis of osteoarthritis?

A

perhaps to rule out other conditions

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15
Q

What are the treatment goals for osteoarthritis?

A

focus on specific lifestyle changes
reduce pain
maintain or improve joint mobility
limit functional disability
improve self-management

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16
Q

What are the 4 pillars of treatment for osteoarthritis?

A
  1. patient education
  2. rehabilitation
  3. medications
  4. referrals
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17
Q

What are some key points about osteoarthritis to educate patients about?

A

importance of exercise, joint protection, strengthening of muscles and supporting joint
importance of weight control

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18
Q

What is the role of exercise in osteoarthritis management?

A

introduction of at home or structured exercise is a key initial management strategy
-ROM, strengthening, aerobic activity
-physiotherapy

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19
Q

What amount of exercise is too much for osteoarthritis?

A

pain lasting > 2 hrs after exercise

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20
Q

What are some environmental adaptations that can be made for osteoarthritis?

A

raised toilet seats
supports, splints, braces
walkers, canes
supportive footwear

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21
Q

What is the most effective intervention for osteoarthritis?

A

non-pharmacological interventions
-most effective but underutilized

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22
Q

What is pharmacotherapy aimed at for osteoarthritis?

A

pain relief

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23
Q

How should pharmacotherapy be initiated for osteoarthritis?

A

monotherapy prn and add/substitute medications as needed

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24
Q

Which medications are options for osteoarthritis?

A

acetaminophen
topical NSAIDs
other topicals (capsaicin, A535)
oral NSAIDs
opioids
duloxetine
injectable joint replacement fluid
injectable glucocorticoids

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25
Q

What is the role of acetaminophen for osteoarthritis?

A

historically was the initial DOC
-recent evidence shows negligible, non sig clinical effect on pain
-guidelines do not strongly recommend anymore
1g QID (max 4g/24h), trial 2-3 wks at max dose then use LED

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26
Q

What is the MOA of acetaminophen?

A

acts within CNS, prevents PG synthesis by blocking COX

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27
Q

What are safety concerns of acetaminophen?

A

does NOT cause liver disease at normal doses
risk is from consuming from multiple sources
lower dose: liver dx, LBW, malnutrition, advanced age

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28
Q

What are the drug interactions of acetaminophen?

A

warfarin
isoniazid
continued alcohol use

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29
Q

Which NSAIDs are available as topicals?

A

diclofenac
ketoprofen

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30
Q

What is the MOA of topical NSAIDs?

A

thought to inhibit COX-2 at the site of action

31
Q

What is the role of topical NSAIDs for osteoarthritis?

A

knee/hand/foot OA
-analgesic effect in hrs, full effect may take a couple wks
-60% achieve a 50% pain reduction
-safety issues and drug interactions are unlikely

32
Q

What is the MOA of capsaicin?

A

depletes substance P and down regulates nociceptive fibers

33
Q

What is the use of capsaicin for osteoarthritis?

A

knee OA

34
Q

How should capsaicin be used for OA?

A

TID-QID to affected joint
must be used consistently for 2-4wks to see improvement

35
Q

What are the side effects of capsaicin?

A

initial burning and sensitivity
systemic effects are rare, case reports of severe burns

36
Q

What is the MOA of methyl salicylate?

A

topical counter irritant

37
Q

What is the role of methyl salicylate in osteoarthritis?

A

limited evidence

38
Q

What are the safety concerns of methyl salicylate?

A

avoid in ASA allergic patients
potential warfarin interaction

39
Q

What is the MOA of oral NSAIDs?

A

bind to COX and prevent the production of PGs

40
Q

What is the role of oral NSAIDs for osteoarthritis?

A

more effective than acetaminophen
preferred if failed topical NSAID, multiple joints affected, or hip or spine OA

41
Q

What are the concerns with oral NSAIDs?

A
  1. CV: risk is with all, effect is dose related
  2. GI: assess risk and consider prophylaxis
  3. renal: risk is with all
  4. drug interactions
42
Q

Which oral NSAID is preferred for osteoarthritis?

A

if concerned about GI toxicity:
-celecoxib or other NSAID + PPI

43
Q

How should oral NSAIDs be used for osteoarthritis?

A

low doses and slow escalation’
switching may help if one failed

44
Q

What are some “other” side effects of NSAIDs?

A

CNS
-dose related, respond to decreased dose
minor or serious skin reactions, pruritis

45
Q

What are the monitoring parameters if oral NSAIDs are used long term?

A

blood pressure
electrolytes
renal function
CBC
INR if on anticoagulants

46
Q

What is the MOA of opioids?

A

bind opioid receptors in CNS and PNS, alters perception and response to pain

47
Q

What is the use of opioids for osteoarthritis?

A

only select patients/last line therapy
-modest benefit at best
-viable option if severe pain or CI to other treatment
-smallest effective dose, shortest duration

48
Q

What are the concerns with using opioids for osteoarthritis?

A

AEs: sedation, nausea, constipation, resp dep, tolerance
fall risk and confusion in elderly

49
Q

What is the MOA of tramadol?

A

binds mu opioid receptors
inhibits reuptake of serotonin and norepinephrine

50
Q

What are the concerns with tramadol?

A

risk of serotonin syndrome
drugs that lower seizure threshold
QT prolongation
requires 2D6 to metabolize

51
Q

What is the role of tramadol for osteoarthritis?

A

guidelines endorse as an option, preferable to opioids
-similar efficacy to oral NSAIDs but more AEs

52
Q

What is the MOA of duloxetine?

A

SNRI

53
Q

What is the role of duloxetine for osteoarthritis?

A

2nd line agent, esp if neuropathic pain
-indications: knee OA (off-label: hip OA)

54
Q

What is the onset of duloxetine for osteoarthritis?

A

improvement may be noted in 1-4 weeks

55
Q

What are the adverse effects of duloxetine?

A

headache
dizziness
dry mouth
constipation
sweating
appetite loss
sedation
fatigue
BP and HR increase at higher doses

56
Q

What are the warnings for duloxetine?

A

GI bleed risk
CNS depression
fracture risk increase
orthostasis
serotonin syndrome
sexual dysfunction

57
Q

What are the contraindications of duloxetine?

A

narrow angle glaucoma
ESRD and hepatic impairment
seizure history

58
Q

What are the drug interactions of duloxetine?

A

risk of serotonin syndrome with SSRIs
clearance decreased by 1A2 and 2D6 inhibitors

59
Q

What is the MOA of injectable corticosteroids?

A

interrupt inflammatory cascade at several levels

60
Q

What is the use of injectable corticosteroids for osteoarthritis?

A

can be considered in hip, knee, shoulder OA

61
Q

Describe the efficacy of injectable corticosteroids for osteoarthritis.

A

short term relief, no long term benefit
pain reduced by average of 1-2 points on 10 point scale

62
Q

What is the onset and duration of injectable corticosteroids?

A

rapid onset
effects typically last 4-8 wks

63
Q

What are the adverse effects of injectable corticosteroids?

A

may accelerate cartilage destruction
post-injection flare
local skin changes
infections

64
Q

What are the warnings for injectable corticosteroids?

A

limited to 3-4 injections in one joint per year
may worsen joint instability or weakness
minimize joint activity for 2-3 days

65
Q

What is the available injectable joint fluid replacement?

A

hyaluronic acid

66
Q

What is the MOA of hyaluronic acid?

A

component of synovial fluid

67
Q

What is the use of hyaluronic acid for osteoarthritis?

A

indicated for knee OA; other types off-label
-efficacy: uncertain benefit, costly

68
Q

What are the adverse effects of hyaluronic acid?

A

arthralgia
injection site pain/reaction
post-injection flare

69
Q

What is glucosamine?

A

precursor to proteoglycan

70
Q

What is the role of glucosamine for osteoarthritis?

A

no official approval, evidence is mixed
not recommended in tx guidelines

71
Q

How long is an adequate trial of glucosamine?

A

need to use for 3 months before results

72
Q

What are the safety concerns of glucosamine?

A

good safety profile
increased INR, bleed risk

73
Q

What is the role of chondroitin for osteoarthritis?

A

less data than glucosamine

74
Q

What are the safety concerns of chondroitin?

A

good safety profile
increased INR, bleed risk

PHAR255 (24 decks)

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