Osteoarthritis Flashcards by Jordan Cyr

What is arthritis?

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

How well did you know this?

Not at all

Perfectly

What is osteoarthritis?

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

How well did you know this?

Not at all

Perfectly

What is the most common form of arthritis?

osteoarthritis

How well did you know this?

Not at all

Perfectly

What is the relationship between osteoarthritis and age?

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

How well did you know this?

Not at all

Perfectly

Describe the etiology of osteoarthritis.

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

How well did you know this?

Not at all

Perfectly

Explain the pathogenesis of osteoarthritis.

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

How well did you know this?

Not at all

Perfectly

What are the risk factors for osteoarthritis?

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

How well did you know this?

Not at all

Perfectly

What are the clinical features of osteoarthritis?

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

How well did you know this?

Not at all

Perfectly

Describe the pain associated with osteoarthritis.

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

How well did you know this?

Not at all

Perfectly

Which joints are commonly affected by osteoarthritis?

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

How well did you know this?

Not at all

Perfectly

How is osteoarthritis often diagnosed?

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

How well did you know this?

Not at all

Perfectly

When is additional testing needed for osteoarthritis?

younger individuals
atypical signs/sx
weight loss

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

perhaps to rule out other conditions

How well did you know this?

Not at all

Perfectly

What are the treatment goals for osteoarthritis?

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

How well did you know this?

Not at all

Perfectly

What are the 4 pillars of treatment for osteoarthritis?

patient education
rehabilitation
medications
referrals

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

What is the role of exercise in osteoarthritis management?

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

How well did you know this?

Not at all

Perfectly

What amount of exercise is too much for osteoarthritis?

pain lasting > 2 hrs after exercise

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

What is the most effective intervention for osteoarthritis?

non-pharmacological interventions
-most effective but underutilized

How well did you know this?

Not at all

Perfectly

What is pharmacotherapy aimed at for osteoarthritis?

pain relief

How well did you know this?

Not at all

Perfectly

How should pharmacotherapy be initiated for osteoarthritis?

monotherapy prn and add/substitute medications as needed

How well did you know this?

Not at all

Perfectly

Which medications are options for osteoarthritis?

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

How well did you know this?

Not at all

Perfectly

What is the role of acetaminophen for osteoarthritis?

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

What is the MOA of acetaminophen?

acts within CNS, prevents PG synthesis by blocking COX

What are safety concerns of acetaminophen?

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

What are the drug interactions of acetaminophen?

warfarin isoniazid continued alcohol use

Which NSAIDs are available as topicals?

diclofenac ketoprofen

What is the MOA of topical NSAIDs?

thought to inhibit COX-2 at the site of action

What is the role of topical NSAIDs for osteoarthritis?

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

What is the MOA of capsaicin?

depletes substance P and down regulates nociceptive fibers

What is the use of capsaicin for osteoarthritis?

knee OA

How should capsaicin be used for OA?

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

What are the side effects of capsaicin?

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

What is the MOA of methyl salicylate?

topical counter irritant

What is the role of methyl salicylate in osteoarthritis?

limited evidence

What are the safety concerns of methyl salicylate?

avoid in ASA allergic patients potential warfarin interaction

What is the MOA of oral NSAIDs?

bind to COX and prevent the production of PGs

What is the role of oral NSAIDs for osteoarthritis?

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

What are the concerns with oral NSAIDs?

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

Which oral NSAID is preferred for osteoarthritis?

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

How should oral NSAIDs be used for osteoarthritis?

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

What are some "other" side effects of NSAIDs?

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

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

blood pressure electrolytes renal function CBC INR if on anticoagulants

What is the MOA of opioids?

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

What is the use of opioids for osteoarthritis?

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

What are the concerns with using opioids for osteoarthritis?

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

What is the MOA of tramadol?

binds mu opioid receptors inhibits reuptake of serotonin and norepinephrine

What are the concerns with tramadol?

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

What is the role of tramadol for osteoarthritis?

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

What is the MOA of duloxetine?

SNRI

What is the role of duloxetine for osteoarthritis?

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

What is the onset of duloxetine for osteoarthritis?

improvement may be noted in 1-4 weeks

What are the adverse effects of duloxetine?

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

What are the warnings for duloxetine?

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

What are the contraindications of duloxetine?

narrow angle glaucoma ESRD and hepatic impairment seizure history

What are the drug interactions of duloxetine?

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

What is the MOA of injectable corticosteroids?

interrupt inflammatory cascade at several levels

What is the use of injectable corticosteroids for osteoarthritis?

can be considered in hip, knee, shoulder OA

Describe the efficacy of injectable corticosteroids for osteoarthritis.

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

What is the onset and duration of injectable corticosteroids?

rapid onset effects typically last 4-8 wks

What are the adverse effects of injectable corticosteroids?

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

What are the warnings for injectable corticosteroids?

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

What is the available injectable joint fluid replacement?

hyaluronic acid

What is the MOA of hyaluronic acid?

component of synovial fluid

What is the use of hyaluronic acid for osteoarthritis?

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

What are the adverse effects of hyaluronic acid?

arthralgia injection site pain/reaction post-injection flare

What is glucosamine?

precursor to proteoglycan

What is the role of glucosamine for osteoarthritis?

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

How long is an adequate trial of glucosamine?

need to use for 3 months before results

What are the safety concerns of glucosamine?

good safety profile increased INR, bleed risk

What is the role of chondroitin for osteoarthritis?

less data than glucosamine

What are the safety concerns of chondroitin?

good safety profile increased INR, bleed risk