Osteoarthritis

Question 1

Acetaminophen

Answer 1

(Tylenol)
analgesic and antipyretic agent

Recommended as 1st line for mild-moderate disease
Efficacy :
More effective than placebo; less effective than NSAIDs

Dose for OA pain:
1000mg PO qid (MAX 4g/day)
FDA says

Question 2

Methyl Salicylate and Menthol patch

Answer 2

SalonPas Patches
Max: 8 hours application; 3 consecutive days
Efficacy shown to be similar to that of oral therapy
Reduced GI and CV adverse events

Question 3

Diclofenac 1% gel

Answer 3

(Voltaren®)
2-4g applied qid (max 32g/day)
Reduced GI and CV adverse events
Efficacy shown to be similar to that of oral therapy

Question 4

Diclofenac 1.5% topical solution

Answer 4

(Pennsaid®)
40 drops applied qid (10 drops at a time)
Reduced GI and CV adverse events
Efficacy shown to be similar to that of oral therapy

Question 5

Diclofenac 1.3% patch

Answer 5

(Flector) – 1 patch BID
Reduced GI and CV adverse events
Efficacy shown to be similar to that of oral therapy

Question 6

Topical Capsaicin

Answer 6

• Monotherapy or in combination
  MOA:
  Depletes substance P from afferent nociceptive nerve fibers

*Apply 2-4 times a day to provide adequate pain relief

Local AE-burning, stinging, erythema
*keep away from eyes and mouth, wash hands after use

Question 7

Corticosteroid Injections

Answer 7

• Intra-articular injections
• Relief from local inflammation or joint effusion
• After injection, minimize stress to joint
• Initial pain relief within 24-72 hours
• Should be used infrequently (4-6 month intervals)

Adverse Effects
Systemic: hyperglycemia, edema, ↑BP, dyspepsia
Local: joint infection, osteonecrosis, tendon rupture, skin atrophy at injection site
Systemic corticosteroids NOT recommended in OA

Question 8

Hyaluronate Injections

Answer 8

Hyalgan®, Supartz®, Synvisc®, Orthovisc®

Hyaluronic acid is an important constituent of synovial fluid

Intra-articular injections

• Temporarily increase viscosity of synovial fluid
• Injected once weekly x 3-5 weeks

Place in Therapy:
Patients that have been unresponsive to other therapies
Not quite yet candidates for surgery

Question 9

Duloxetine

Answer 9

(Cymbalta)
SNRI

Knee OA only???

Dosage:
Starting @ 30mg PO once daily titrated up to 60mg PO once daily (FDA approved- max dose 60mg/day)

Side effects:
Nausea (23%), dry mouth (13%), headache (12%), constipation (10%), dizziness, fatigue, decreased appetite
Cognitive effects/memory?

May be beneficial for patients with comorbidities
Indicated for neuropathic pain also

Drug interactions: Substrate and moderate inhibitor of CYP2D6

Question 10

Tramadol

Answer 10

(Ultram®, Rybix®, Ryzolt®)
Opioid analgesic

*May be useful as add-on therapy or for patients who cannot take NSAIDs
Should be initiated at lower dose (100mg/day)

Common AE:
N/V, dizziness, constipation, HA, somnolence
INTERACTION: SSRI’s
↑ risk of serotonin syndrome

Question 11

Tapentadol ER

Answer 11

(Nucynta)
Centrally acting analgesic with µ-opioid receptor agonism and norepinephrine reuptake inhibition

Dosage:
100-250mg ER PO bid

Efficacy in knee OA

AE: Nausea, vomiting, somnolence, dizziness
*Better GI tolerability than opioids

Question 12

Glucosamine and Chondroitin

Answer 12

Modulate articular cartilage matrix metabolism

Dose: At least 1500mg/day of glucosamine and 1200mg/day of chondroitin

Efficacy: variable results from RCTs

Place in Therapy:
Still unclear
Relatively safe; reasonable alternative or to use in combo
Caution in patients with shellfish allergy
Counseling points related to herbal products