Osteoarthritis Flashcards
1
Q
What is the most common type of arthritis?
A
Osteoarthritis
2
Q
What is osteoarthritis?
A
Chronic, progressive disorder characterized by the loss of articular cartilage in primarily hands, knees, hips and spine
3
Q
What is the peak age of onset for osteoarthritis?
A
50 to 60 years old
Prevalence depends on population, but increases as we age
4
Q
What is the incidence of osteroarthritis in older adults?
A
Nearly half of the population
A lot of patients self-medicate and are not captured by statistics
5
Q
What is the mechanism of action of primary osteoarthritis?
A
MOA not completely understood
6
Q
What is the mechanism of secondary osteoarthritis?
A
Other metabolic factors at play (ex. hemochromatosis, acromegaly)
7
Q
How is joint trauma a factor in the development of osteoarthritis?
A
- Biochemical and mechanical changes
- Loss of functionality
- Changes in cartilage, joint capsule, subtracheal bone
8
Q
What causes 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 matrix metalloproteinases
9
Q
What are the stages of progression for osteoarthritis?
A
- Articular cartilage changes
- Bone remodelling
- Synovial inflammation
- Soft tissue inflammation
10
Q
What are some modifiable risk factors for osteoarthritis?
A
- Obesity
- Joint trauma
11
Q
What are some non-modifiable risk factors for osteoarthritis?
A
- Age
- Genetics
- Sex (hand and knees more common in women, hips (men and women with equal occurance)
- Joint misalignment/deformity
12
Q
What are the most common clinical features associated with osteoarthritis?
A
- Initial absence of inflammation or joint swelling
- Mono-articular at first
- Pain and stiffness with activity
- No systemic symptoms
13
Q
What are some minor clinical features associated with osteoarthritis?
A
- Crepitus (crunching sound from bones and cartilage grinding)
- Tenderness
- Limited range of motion
- Bony swelling
- Joint deformity
- Instability
14
Q
What are the stages of pain associated with osteoarthritis?
A
Stage 1: Predictable, sharp pain brought on by activity (impact on function)
Stage 2: Pain becomes more constant; episodes of stiffness; episodes of intense, exhausting pain
15
Q
What are some commonly affected joints in osteoarthritis?
A
- In the fingers (phalangeal joints), joints of thumb
- Cervical and lumbar spine
- Hip, knee, in the feet
16
Q
What are some common deformities found in the hands of osteoarthritis patients?
A
- Heberden’s nodes
- Bouchard’s nodes
17
Q
What are the standard diagnostic criteria for osteoarthritis?
A
- Persistent usage-related plan
- Age over 45
- Little early morning stiffness, more evening stiffness
18
Q
Which patient groups need additional testing to confirm osteoarthritis diagnosis?
A
- Younger individuals
- Atypical signs or symptoms
- Weight loss
19
Q
What are the goal of treatment for osteoarthritis?
A
- Reduce pain
- Maintain or improve joint mobility
- LImit functional disability
- Improve self-management
20
Q
What are the four pillars of treatment?
A
- Patient education
- Rehabilitation
- Medications
- Referrals (surgical and non-surgical)
21
Q
What are some patient education tips for osteoarthritis?
A
- Emphasize importance of exercise, joint protection, strengthening of muscles, and supporting joint with activity modification
- Emphasize importance of weight control (12lbs drop in women = 50% reduction in risk, can also reduce pain)
- Benefits, harms, costs, expectation of treatment options
22
Q
What are some exercise tips for osteoarthritis patients?
A
- Home or structured exercise
- Range of motion, strenthening, aerobic activity (Tai Chi, Yoga, Balance exercises)
- Land-based vs. aquatic (both are good, more evidence for land based)
- What is too much? (Pain lasting more than 2h after exercise)
- Physiotherapy
23
Q
What are some environmental modifications that can help osteoarthritis patients improve their rehabilitative care?
A
- Raised toilet seats, home or work adaptations
- Supports, splints, braces
- Canes, walkers
- Supportive footwear, shock absorbing orthotics (does the work of healthy cartilage)
24
Q
What type of interventions in osteoarthritis are the most effective?
A
Non-pharmacologic interventions remain the most effective, but underutilized interventions for OA
25
What is the focus of pharmacological treatment in osteoarthritis?
Drug therapy is targeted at pain relief (start monotherapy, and add/sub meds as needed)
PO, topical, intrarticular
26
What are the types of pharmacological treatments for osteoarthritis?
1. Acetaminophen
2. Topical NSAIDs
3. Other topical (capsaicin, a535)
4. Oral NSAIDs
5. Opioids (traditional and tramadol)
6. Duloxetine
7. Injectable joint replacement fluid
8. Injectable glucocorticoids
9. Others
27
What is the role of acetaminophen in treatment of osteoarthritis?
Traditional DOC, not anymore due to newer evidence
Negligible, non-clinically significant effect on pain
MOA: acts centrally, prevents PG synthesis by blocking COX
28
What is the safety profile of acetaminophen in osteoarthritis treatment?
- Does not cause liver disease at normal doses
- Risk from patients consuming from multiple products
- Lower doses for patients with liver dysfunction, malnutrition, low body weight, old age (especially with chronic dosing)
29
What are some drug interactions associated with acetaminophen?
- Warfarin (at higher doses)
- Continued alcohol use (increased liver damage)
- Isoniazid
30
What is the mechanism of action of topical NSAIDs in osteoarthritis?
Thought to inhibit COX-2 near the site of action (safer than oral NSAIDs)
31
What joints are topical NSAIDS best indicated for in osteoarthritis?
Knee, hand, foot OA
Not hip because it is not at surface and also a bigger joint
32
What are some characteristics of topical NSAID treatment in osteoarthritis?
- Applied BID (with diclofenac, Voltaren ES)
- Analgesic effect in hours, full effect may take a couple of weeks
- 60% of patients acheive at least 50% pain reduction
- Safety issues, drug interactions unlikely (lower compared to oral NSAIDs)
33
What is the mechanism of action for capsaicin?
Depletes substance P and down-regulates nociceptive fibers (especially useful in post-herpectic neuralgia)
34
What joint is best indicated for capsaicin treatment in osteoarthritis?
Knee OA
35
What are the characteristics of capsaicin treatment in osteoarthritis?
- Superior to placebo
- Apply to joint TID to QID
- Must be used consistently for 2-4 weeks to see improvement
- Initial burning and sensitivity
- Systemic effects are rare, case reports of severe burns
36
What is the mechanism of action of RUB A535 in osteoarthritis?
Acts as a topical counterirritant (not recommended, but a lot of patients use it)
37
What are some characteristics of capsaicin treatment in osteoarthritis?
- Apply TID to QID
- Little evidence to support use
- Not well studied in controlled environment
- Avoid in ASA allergic patients, potential warfarin interaction
38
What is the mechanism of action of oral NSAIDs in osteoarthritis treatment?
Bind to COX and prevent the production of prostaglandins
39
What are the characteristics of oral NSAIDs in osteoarthritis?
- More effective
- Risk of GI/CV/renal toxicity
- Preferred if topical NSAID failed, multiple joints affected, or hip and spine OA
- First reccomended oral agent
40
What are some concerns associated with oral NSAIDs?
1. CV (risk is with all, the effect is dose related. Naproxen is likely safest)
2. GI (bleeds, ulcers, obstructions), assess risk and consider PPI prophylaxis
3. Renal (risk is with all, avoid NSAIDs in CKD)
4. Drug interactions
41
Which is the preferred oral NSAID for treating osteoarthritis?
- Celecoxib or other NSAID+PPI
42
Review slides 32 and 33 for NSAID risk factors and choices in osteoarthritis treatment
43
What are some CNS adverse events associated with oral NSAIDs?
- Dizziness
- Drowsiness
- Headache
- Tinnitus
- Confusion (especially in the elderly)
- CNS effects may be dose related and respond to the decreased dosage
44
What are some monitoring parameters for oral NSAIDs?
- Blood pressure
- Electrolytes
- Renal function
- CBC (hemoglobin to monitor GI bleeds)
- INR in patients taking anticoagulants
45
What is the mechanism of action of traditional opioids in osteoarthritis?
Bind to opioid receptots in CNS and PNS, alters perception and response to pain
46
What is the role of traditional opiods in treatment of osteoarthritis?
Only recommended in select patients/last line therapy
- Modest benefits for risks associated with use
- Viable treatment for severe pain or CI to other agents
- Use smallest effective dose for shortest duration possible
47
What are some concerns associated with traditional opioids in osteoarthritis treatment?
- Sedation
- Nausea, constipation
- Respiratory depression (can be lethal)
- Tolerance
- Increased risk of falls/fractures (especially in elderly patients)
- Confusion
48
What is the mechanism of action of Tramadol in osteoarthritis treatment?
Centrally acting analgesic that binds to opioid receptors and also inhibits reuptake of serotonin and norepinephrine (dual weak opioid agonism and SNRI action)
49
What are some concerns with the use of Tramadol in osteoarthritis treatment?
Similar to opioids, risk of serotonin syndrome, drugs that lower seizure threshold, QT prolongation, requires 2D6 to metabolize
50
What is the mechanisms of action of Duloxetine in osteoarthritis treatment?
SNRI (inhibit the reuptake of serotonin and norepinephrine)
51
What are some pain indications for Duloxetine?
- Depression
- Anxiety
- Neuropathic pain (DM)
- Fibromyalgia
- Chronic low back pain
- OA of the knee
52
What is the onset of action of Duloxetine in osteoarthritis?
Improvement may be noted in 1-4 weeks
53
What are some adverse effects associated with Duloxetine in osteoarthritis treatment?
- Headache, dry mouth, constipation, sedation, fatigue, dizziness, sweating, appetite loss
- BP and HR increases at high doses
54
What are some warnings associated with Duloxetine?
- GI bleed risk
- CNS depression
- Fracture risk increase
- Orthostatic hypotension
- Serotonin syndrome
- Sexual dysfunction
55
What are the contraindications for duloxetine in patients with osteoarthritis?
- Narrow angle glaucoma
- ESRD and hepatic impairment
- Seizure hisotry
56
What are some drug interactions associated with osteoarthritis?
- Risk of serotonin syndrome with SSRIs
- Clearance may be decreased by CYP1A2 or 2D6 inhibitors
57
What are some examples of corticosteroids that are injectable for use in osteoarthritis?
- Triamcinolone
- Methylprednisolone
- Hydrocortisone
- Dexamethasone
58
What is the mechanism of action of injectable corticosteroids in osteoarthritis treatment?
Interrupt inflammatory cascade at several levels
59
Which joints are best indicated for injectable corticosteroid treatment in osteoarthritis?
Can be considered in hip, knee, shoulder OA
60
What is the efficacy of injectable corticosteroid treatment in osteoarthritis?
- Short-term relief, no long-term benefit
- Pain reduced by an average of 1-2 points on 10 point scale
61
What is the onset and duration of injectable corticosteroid treatment?
Rapid onset, effects typically last 4-8 weeks
62
How are injectable corticosteroids for osteoarthritis dosed?
Varies depending on size of joint
63
What are some adverse effects associated with injectable corticosteroids in osteoarthritis?
- May accelerate cartilage degradation (esp. hand)
- Post-injection flare
- Local skin changes
- Infections
64
What are some warning for the use of injectable corticosteroids for osteoarthritis?
- LImited to 3-4 injections in one joint per year
- May worsen joint instability or weakness
- Minimize joint activity for 2-3 days
65
What is the mechanism of action of injectable joint fluid replacement in osteoarthritis?
Hyaluronic acid is a component of synovial fluid and it is injected into the joint to improve lubrication
66
What joint is injectable joint fluid replacement best indicated for in osteoarthritis?
Indicated for knee OA officially, other types are off-label
67
What is the efficacy of injectable joint fluid replacement in osteoarthritis?
Uncertain benefit, costly ($200 to $300)
68
How is injectable joint fluid replacement in osteoarthritis dosed?
Intraarticular injection once weekly for 2-4 weeks, may repeat cycle every 6 months
69
What is the onset and duration of injectable joint fluid replacement in osteoarthritis?
- Rapid in some, others require completed cycle
- May last longer than intra-articular steroids
70
What are some adverse effects associated with injectable joint fluid replacement in patients with osteoarthritis?
Arthralgia, injection site pain/reaction, post-injection flare
71
Is glucosamine a recommended treatment option for osteoarthritis?
Not recommended in treatment guidelines
72
What are some surgical options for the treatment of osteoarthritis?
- Osteotomy (removal of bony tissue): reduce pain and improve knee function
- Debridement (orthoscopic surgery)
- Joint replacement (arthoplasty): becoming more common, debate on how early arthoplasty should be performed
73
Review slides 49 to 51 for summarized osteoarthritis treatment guidelines
