Osteoarthritis Flashcards
1
Q
What is OA?
A
Chronic, progressive disorder characterized by the loss of articular cartilage in primarily hands, knees, hips and spine
2
Q
True or False? The most common form of arthritis is OA
A
True
3
Q
Peak age of onset of OA is?
A
50-60 years
4
Q
The MOA of OA is not completely understood, but what is the primary and secondary etiology of it?
A
Primary - no identifiable factor
Secondary - other metabolic factors identified (i.e., hemachromatosis, acromegaly)
5
Q
How is joint trauma a factor of OA? (3)
A
- Biochemical and mechanical changes –>
- Loss of functionality –>
- Changes in cartilage, joint capsule, subtracheal bone
6
Q
Describe the pathogenesis of OA (3)
A
- Imbalance between cartilage maintenance and destruction
- Role of inflammatory cytokines (TNF, IL-1)
- Role of matrix metalloprotease
7
Q
Describe how the imbalance between cartilage maintenance and destruction can cause OA (3)
A
- Malfunction of chondrocyte (responsible for cartilage breakdown)
- End result is loss of proteoglycans and water
- Formation of osteophytes (bony outgrowths)
8
Q
What are the 2 modifiable risk factors for OA?
A
- Obesity
- Joint trauma
9
Q
What are the 4 non-modifiable risk factors for OA?
A
- Age
- Genetics
- Sex
- Joint misalignment/deformity
10
Q
What are the clinical features of OA? (5 main ones)
A
- Gradual onset
- Initial absence of inflammation or joint swelling
- Mono-articular at first
- Pain and stiffness with activity
- No systemic symptoms
11
Q
How many stages of pain are there in OA?
A
3
12
Q
Describe stage 1 pain of OA
A
Predictable, sharp pain brought on by activity
13
Q
Describe stage 2 pain of OA
A
Pain becomes more constant; episodes of stiffness
14
Q
Describe stage 3 pain of OA
A
Constant dull/aching pain; chronic stiffness; episodes of intense, exhausting pain
15
Q
With OA, pain tends to be worse at what time of day?
What other quality might this pain have?
A
- Tends to be worse later afternoon/early evening
- May have a neuropathic quality
16
Q
What are the joints commonly affected in OA?
A
- Distal interphalangeal (DIP), proximal interphalangeal (PIP), joints of thumb
- Cervical and lumbar spine
- Hip, knee, meotarsophalangeal joint
17
Q
What are 2 deformities seen with OA?
A
- Heberden’s nodes (at DIP)
- Bouchard’s nodes (at PIP)
18
Q
OA is often diagnosed WITHOUT ___________ or ___ ______
A
radiography; lab tests
19
Q
In general, OA is diagnosed if: (3)
A
- Persistent usage-related pain
- Age > 45 years
- Little early morning stiffness; more evening stiffness
20
Q
Additional testing for OA diagnosis will be needed if there are these criteria: (3)
A
- Younger individuals
- Atypical signs or symptoms
- Weight loss
21
Q
What are the 4 main components of OA diagnosis?
A
- History
- Physical exam
- Imaging
- X-ray may be helpful for diagnostic clarification or monitoring
- Does not necessarily correlate with pain - Laboratory tests
- To rule out other conditions mostly
22
Q
What are the goals of OA treatment? (5)
A
- Focus on specific lifestyle changes
- Reduce pain
- Maintain or improve joint mobility
- Limit functional disability
- Improve self-management
23
Q
What are the 4 pillars of treatment of OA?
A
- Patient education
- Rehabilitation
- Medications
- Referrals
- Surgical
- Non-surgical
24
Q
True or False? OA can be cured
A
False - can only manage for the most part
25
In terms of patient education, what should we be telling patients about OA? (4)
1. Explain nature of OA as a chronic disease process. Refer to resources
2. Emphasize importance of exercise
3. Emphasize importance of weight control
4. Benefits, harms, costs, expectation of treatment options
26
What are some (4) aspects of OA rehabilitation?
1. Exercise
2. Relaxation, Mind/Body
3. Other
- Acupuncture (meh)
- Thermal interventions
4. Environmental changes/aids
27
What are some components of exercise that should be implemented for OA rehabilitation? (5)
1. Introduction of at home or structured exercise is a key initial management strat
2. Range of motion, strengthening, aerobic activity
3. Land-based vs. aquatic based
4. What is too much?
- In general, pain in joint lasting >2 hours after exercise
5. Physiotherapy
28
What are some examples of relaxation, mind/body that can be utilized for OA rehabilitation? (4)
1. Tai Chi - knee and hip OA
2. Yoga - knee OA
3. Balance exercises - knee and hip OA
4. Cognitive behavioural therapy (CBT) - knee, hip, and hand
29
What are some examples of environmental changes/aids involved in OA rehabilitation? (4)
1. Raised toilet seats, home or work adaptations
2. Supports, splints, braces
3. Canes, walkers
4. Supportive footwear, shock absorbing orthotics
30
What are 4 characteristics/principles of medication treatment of OA?
1. Drug therapy is targeted at pain relief
2. Treatment should be conservative and individualized
3. Begin with monotherapy prn and add/substitute medications as needed
4. PO, topical, intrarticular
31
What are the 8 medication OA treatment options?
1. Acetaminophen
2. Topical NSAIDs
3. Other topicals (capsaicin, a535)
4. Oral NSAIDs
5. Opioids (traditional and tramadol)
6. Duloxetine
7. Injectable joint replacement fluid
8. Injectable glucocorticoids
32
True or False? Non-pharmacological interventions are not really useful for OA
False - they remain the most effective, but underutilized interventions for OA
33
What is the MOA of acetaminophen?
Acts within the CNS, prevents prostaglandin synthesis by blocking COX
34
What is the dosing of acetaminophen in OA?
1. Up to 1g QID (max 4g in 24h)
2. Appropriate trial 2-3 weeks at maximum doses, then use lowest effective dose
35
What are some safety concerns to keep in mind when using acetaminophen? (3)
1. Does not cause liver disease at normal doses
2. Risk from pts consuming from multiple sources
3. Lowered doses prudent for patients with:
- Liver disease
- Malnutrition, low body weight, advanced age, especially with chronic dosing
36
What are some (3) DIs to be aware of when using acetaminophen?
1. Warfarin (at higher doses)
2. Continued alcohol use
3. Isoniazid
37
What are 2 topical NSAIDs that might be used in OA?
1. Diclofenac (1.5% solution, 1.16 & 2.32% gel, and compounded %)
2. Ketoprofen compounded
38
What is the MOA of topical NSAIDs for OA?
Thought to inhibit COX-2 near the site of action
39
What are the characteristics of topical NSAIDs? i.e.,;
- How often applied?
- How long until they take effect?
- Efficacy?
- Safety?
1. Applied BID (with diclo/voltaren ES) to QID (others)
2. Analgesic effect in hours, full effect may take a couple of weeks
3. 60% of patients achieve at least 50% pain reduction
4. Safety issues, drug interactions unlikely
40
What is the MOA of topical capsaicin for OA?
Depletes substance P and down-regulates nociceptive fibers
41
What are the characteristics of topical capsaicin in OA? i.e.,;
- Efficacy
- How often to apply
- How long to use
- Safety (2)?
1. Superior to placebo
2. Apply to joint TID-QID
3. Must be used consistently for 2-4 weeks to see improvement
4. Initial burning and sensitivity
5. Systemic effects are rare, case reports of severe burns
42
What are the 2 topical capsaicin strengths?
1. 0.025%
2. 0.075%
43
Where are topical NSAIDs typically used? (3)
1. Knee
2. Hand
3. Foot
44
Where is topical capsaicin used on the body?
Knee OA
45
What is the MOA of topical methyl salicylate?
Acts as a topical counter irritant
46
What are the characteristics of methyl salicylate for OA? i.e.,;
- How often to apply
- Efficacy (2)
- When to avoid?
1. Apply TID-QID
2. Little evidence to support use
3. Not well studied in controlled environment
4. Avoid in ASA allergic patients, potential warfarin interaction
47
What is the MOA of oral NSAIDs?
Bind to COX and prevent the production of prostaglandins
48
What are the characteristics of oral NSAIDs in OA? i.e.,;
- Efficacy
- Risks
- When to use
1. More effective than acetaminophen
2. Risk of GI/CV/renal toxicity
3. Preferred if topical NSAID failed, multiple joints affected, or hip and spine OA
49
What are the 4 concerns of using oral NSAIDs?
1. CV - risk is with all; the effect is dose related
2. GI - serious complications <1% per year; assess risk and consider prophylaxis
3. Renal - risk is with all
4. Drug interactions
50
How should oral NSAIDs be used in OA? (2)
1. Utilize low doses and slow escalation
2. Switching may help if one failed
51
What to monitor when on long-term oral NSAID therapy? (5)
1. Blood pressure
2. Electrolytes
3. Renal function
4. CBC
5. INR in patients taking anticoagulants
52
What is the MOA of opioids?
Bind to opioid receptors in CNS and PNS, alters perception and response to pain
53
When are opioids used in OA? (3)
Only recommended in select pts/last-line therapy
- The evidence for efficacy suggests modest benefits at best
- Viable treatment option for severe pain or CI to other agents
- Smallest effective dose for shortest duration as possible
54
What are the concerns (AEs) regarding opioid use in OA? (7)
- Sedation
- Nausea
- Constipation
- Respiratory depression
- Tolerance
- Increased risk of falls/fractures in elderly, confusion
55
What is the MOA of tramadol?
Centrally acting analgesic that binds to mu-opioid receptors. Also inhibits reuptake of serotonin and NE
56
What are the concerns regarding tramadol? (5)
1. Similar to opioids
2. Risk of serotonin syndrome
3. Drugs that lower seizure threshold
4. QT prolongation
5. Requires 2D6 to metabolize
57
What's the dosing of tramadol?
Dose 1-2 tabs Q4-6h prn (max 8 tabs per day)
58
What is the MOA of duloxetine in OA?
SNRI
- Utilized as a second-line agent, esp. if neuropathic pain
59
What are the indications for duloxetine? (6)
1. Depression
2. Anxiety
3. Neuropathic pain (DM)
4. Fibromyalgia
5. Chronic low back pain
6. OA of the knee (off-label: OA of hip)
60
How long until onset of effect of duloxetine for OA?
1-4 weeks
61
What are the AEs of duloxetine? (8)
1. Headache
2. Dry mouth
3. Constipation
4. Sedation
5. Fatigue
6. Sweating
7. Appetite loss
8. BP and HR increases at high doses
62
What are some warnings to be aware of when using duloxetine? (6)
1. GI bleed risk
2. CNS depression
3. Fracture risk increase
4. Orthostatic hypotension
5. Serotonin syndrome
6. Sexual dysfunction
63
What are 3 CIs of duloxetine?
1. Narrow angle glaucoma
2. End-stage renal disease and hepatic impairment
3. Seizure history
64
What are 2 DIs seen with duloxetine?
1. Risk of serotonin syndrome with SSRIs
2. Clearance may be decreased by CYP1A2 or 2D6 inhibitors
65
What is the MOA of injectable corticosteroids for OA?
Interrupts inflammatory cascade at several levels
66
Where might injectable corticosteroids be used?
Can be considered in hip, knee, shoulder OA
67
What is the efficacy of injectable corticosteroids? (2)
1. Short-term relief, no long-term benefit (depends on how long it lasts for the pt)
2. Pain reduced by an average of 1-2 points on 10 point scale
68
What is the onset and duration of injectable corticosteroids?
Rapid onset, effects typically last 4-8 weeks
69
What are 4 AEs associated with injectable corticosteroids?
1. May accelerate cartilage degradation (esp. hand)
2. Post-injection flare
3. Local skin changes
4. Infections
70
What are 3 warnings for using injectable corticosteroids?
1. Limited to 3-4 injections in one joint per year
2. May worsen joint instability or weakness
3. Minimize joint activity for 2-3 days
71
What is the MOA of injectable joint fluid replacement?
Hyaluronic acid is a component of synovial fluid
72
Where might injectable joint fluid replacement be used?
Indicated for knee OA; other types off-label
73
What is the efficacy of hyaluronic acid?
Uncertain benefit, costly
74
What is the onset and duration of hyaluronic acid injection for OA? (2)
1. Rapid in some; others require completed cycle
2. May lost longer than intra-articular steroids
75
What are the AEs of hyaluronic acid injection? (3)
1. Arthralgia
2. Injection site pain/reaction
3. Post-injection flare
76
Glucosamine and chondroitin for OA. Yay or nay?
Not recommended in treatment guidelines, BUT they're pretty safe so worth a try
77
What are 3 surgeries used in OA?
1. Osteotomy (removal of bony tissue)
2. Debridement (orthoscopic surgery)
3. Joint replacement (arthoplasty)
78
What are 4 other occupations to refer OA patient to?
1. Dietician
- Education on weight managment
2. Physiotherapy or Occupational Therapy
- Exercises and such
3. Physician
- Pain medication
4. Rheumatologist or Internal Medicine specialist
- Red flag conditions, unusual complications
