Osteoarthritis Flashcards
What is Osteoarthritis?
Disease of synovial joints where articular cartilage loss leads to and accompanying periarticular bone response
Most common form of arthrititis. affects more women than men
Major cause of locomotor disability
Describe the progression of Osteoarthritis
- Initial repair - Proliferation of chrondrocytes synthesising ECM of bone
- Early stage OA -
Degradation of ECM exceeds chrondrocyte activity resulting in net breakdown and loss of articular cartilage in joint - Intermediate stage OA =
Failure of ECM synthesis and increased breakdown of cartilage - Late-stage OA -
Extreme or complete loss of cartilage with joint space narrowing
Bony outgrowths appear at joint margins (osteophytes)
General bone sclerosis
Pain and reduced joint movement
What are the risk factors of Osteoarthritis
Increasing age. above 65 yrs = 65% in women and 58% in men
Gender
Race - Less common in Chinese, Afro-caribbeans and Asians compared to Europeans
Genetic predisposition
Obesity (63%)
Physical + occupational factors e.g. farmers
Trauma
Describe the Symptoms of Osteoarthrititis
- Joint pain (worse with movement)
- Synovial thickening
- Deformity of joint
- Bone swelling ( Herberden’s or Bouchard’s nodes)
- Joint Effusion
- Muscle weakening
- Crepitus
- Limited joint movement
How would we diagnose Osteoarthritis?
- Clinical presentation e.g. location of affected joint, pain
- X-ray e.g. narrowing of joint space, Bony protrusions (osteophytes), Bone sclerosis (abnormal bone density)
- Arthroscopy .e.g. yellowing, irregular and ulcerated cartilage often present
What are the treatment goals of Osteoarthritis ?
- Reduce pain
- Increase mobility
- Reduce disability
- Minimise disease progression
Non-drug/ complementary treatment options?
60% reported to benefit from non-drug treatments
- exercise
- weight loss
- physical therapy
- education
1.Nutriceuticals e.g. glucosamine (NOT rec by NICE)
2. Acupuncture - Not electro-acupuncture (NICE guidelines)
3, Magnets, copper bracelets
What are the management medications can patients take?
- FIRST CHOICE- Paracetamol upto 4g daily OR paracetamol/opiate combination.
- Topical NSAIDs preparation have less risk of GI effects with Oral e.g. ibuprofen, ketoprofen, felinbac, pixoxicam
- Low dose of NSAIDs with PPI and COX2 inhibitors can be used if pain not controlled.
Other than pain relief what else can be taken for management?
Intra-articular corticosteroid injection for moderate to severe pain
- Intra-articular injection of hyaluronic acid derivatives (NOT recommended by NICE)
- Rubefacients (counter-irritants) not recommended by NICE
- Surgery
What are the cautions of Topical NSAIDs?
systemic effects such as hypersentivity and asthma can still occur if large amounts are used.
Must discontinue use if rash appears.
avoid sunlight exposure to avoid possibility of photo sensitivity
What are Rubefacients? give an example
Counter-irritants that cause redness, dilate capillaries thus increasing blood flow to area
e.g. Capsaicin (0.025%)
Cautions and counselling points of Rubefacients?
Might take 1-2 weeks of use before pain relief is achieved
Washing hands important to ensure that contact with eyes etc is avoided!
Not to be applied to inflamed or broken skin
Transient burning sensation can occur during initial treatment esp. if too much cream is applied or if used less than 3-4 times per day
Burning sensation may be increased if applied to skin after hot bath/shower
Define Spondylarthropathies
Inflammatory rheumatic diseases that include:
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis (Arthritis associated with inflammatory bowel disease)
Describe Ankylosing Spondylitis. Who does it affect?
Inflammation of sacroiliac joint moves up the spine leading to symptoms.
More common in MEN
95% are HLAB27 antigen positive.
Pain improves with exercise but not at rest.
What can the progression of Ankylosing Spondylitis lead to?
Progression of disease leads to spinal fusion (ankylosis) that decreases spinal movement and can lead to spinal kyphosis, sacroiliac joint fusion, neck hyper-extension and rotation
Accoding tot he modifeied New York criteria what does a definite diagnosis of ankylosing spondylitis require?
requires the radiological criterion and at least one clinical criterion.
What is the New York criteria for diagnosis of ankylosing spondylitis?
1.Radiological criterion:
Sacroilitis at least grade 2 bilaterally or grade 3 or 4 unilaterally
2. Clinical criteria:
Low back pain and stiffness for more than 3 months that improves with exercise but is not relieved by rest
Limitation of motion of the lumbar spine in both the sagittal and frontal planes
Limitation of chest expansion relative to normal values for age and sex
All alternative causes of symptoms (e.g. spinal fracture, disc disease and fibromyalgia) must be excluded
How do we assess ankylosing spondylitis?
Using the BASDAI scoring system
Bath AS disease activity index
Describe the Bath AS disease activity index scoring system?
consists of 10cm visual analog scales used to answer 6 questions pertaining to the 5 major symptoms of AS
Fatigue (How tired?)
Spinal pain (How painful?)
Joint pain / swelling (How painful?)
Areas of localized tenderness (Any tenderness?)
Morning stiffness (Present? Duration?)
How is it defined using the Bath AS disease activity index (BASDAI) score?
Goes from 0 to 10
Mild AS is 1-3
Moderate AS is 4-7
Severe AS is 8-10
Treatment options for ankylosing spondylitis? (4)
- Exercise x2 daily
- Slow release NSAIDs taken at night
- Sulfasazaline or methotrexate - may help peripheral arthritis but no evidence for spinal
- Cytokine Modulators - recommended by NICE for those that have failed to respond to two NSAIDs at max dose for 4 weeks
How do cytokine modulators work? In particular Adalimumab, Etanercept, Infliximab and Golimumab
Adalimumab - Antibody that binds to TNF-alpha blocking its interaction with receptors
Etanercept - TNF-alpha receptor fusion protein that inhibits TNF-alpha activity
Infliximab - Antibody that binds to TNF-alpha and neutralises its activity
Golimumab- Anti-TNF drug
What is the mechanism of action of Diclofenac sodium?
An NSAID: Non-selective cyclooxygenase (COX) inhibitor; Inhibits COX enzymes leading to inhibition of prostaglandin synthesis and anti-inflammatory actions
What is the dose of Diclofenac sodium used for pain and inflammation in rheumatic disease?
75mg-150mg daily in 1-2 times daily, modified release for AS
