Osteoarthritis Treatment Flashcards
1
Q
What are the OA Assessment Instruments?
A
- WOMAC OA Index
- Lequesne Index
2
Q
What does the WOMAC OA Index assess?
A
- Pain, stiffness
- Physical, social, emotional function
3
Q
What does the Lequesne Index assess?
A
- Pain/Discomfort
- Maximum distance walked
- Activities of daily living
4
Q
What are the Non-Drug Treatment options for OA?
A
- Patient Education
- Self-Management Programs
- Association between alcohol intake and OA severity
- Social Support
- Diet
5
Q
What are dietary supplements that are unconventional in remedy of OA?
A
Fish oil, primrose oil, herbal/vitamins, honey & vinegar, and golden raisins & gin
6
Q
Which dietary supplement inhibits the arachidonic acid pathway?
A
Fish Oil
7
Q
Which dietary supplement inhibits arachidonic acid?
A
Evening primrose oil
8
Q
What is a non-drug treatment option that is very important in OA?
A
Physical/Occupational Therapy
9
Q
What are things to consider under Physical/Occupational Therapy?
A
- Exercise: low impact
- Assistive Devices
- Joint Protection
- Heat or Cold
- Paraffin
- TENS
10
Q
What is the goal in the treatment of OA?
A
Relieve pain, and preserve function
11
Q
What are the analgesics that can be used in the treatment of OA?
A
- Acetaminophen
- Salicylate, NSAIDs
- Opioids, Codeine
- Tramadol
- Duloxetine
12
Q
What is the dosing for APAP in OA?
A
650 mg/dose, 3250 mg/day
13
Q
What is the dosing for APAP in OA patient with liver disease?
A
<2000 mg/dose
14
Q
What is the dosing schedule for APAP in OA?
A
PRN
15
Q
Which Analgesic has limited effectiveness in OA?
A
APAP
16
Q
Opioids and Codeine are not recommended in elderly due to what?
A
Increased fall and fracture risk
17
Q
Which analgesic used in OA can lead to QT Prolongation and Serotonin Syndrome?
A
Tramadol
18
Q
What analgesic is most useful in OA with depression or widespread pain?
A
Duloxetine
19
Q
What is the analgesic dose of ASA?
A
325-640 QID
20
Q
ALL NSAID effect is on what?
A
Cyclooxygenase
21
Q
Which analgesic have an irreversible effect on COX?
A
ASA
22
Q
What is the function of COX-1?
A
Housekeeping Enzyme
1. Normal cell process
2. Found in most tissue
3. Prevalent in GI
4. Regulate thromboxane
23
Q
What is the function of COX-2?
A
Increases inflammation
1. Regulate prostacyclin
24
Q
Which drug is a Selective COX-2 Inhibitor?
A
Celecoxib/Celebrex
25
Do NSAIDs affect lipoxygenase pathway?
NO
26
What are the effects of NSAIDs?
1. Anti-Inflammatory
2. Analgesic
3. Antipyretic
27
What is considered more effective than APAP in OA?
NSAIDs
28
What are the MAJOR side effects of NSAIDs?
1. Gastrointestinal
2. Renal
3. Hematologic
4. Cardiovascular
29
Where is the Primary Insult of NSAIDs?
Direct Acid Damage
30
What is the Secondary Insult of NSAIDs?
Prostaglandin Inhibition, systemic effect
31
What are 3 steps in preventing NSAID Esophageal Injury?
1. Upright Position
2. Sufficient Liquid >120 mL
3. Not immediately before bedtime
32
What can be used to prevent NSAID Ulcers?
Proton Pump Inhibitors PPI, decrease risk and promote healing
33
What is an alternative to PPI in prevention of NSAID Ulcers?
Misoprostol
34
What is the problem with Misoprostol?
1. High incidence of GI side effects
2. CI in pregnancy
35
In patients with CHF, volume contraction, and cirrhosis/ascites, they have increased adrenergic and renin-angiotensin systems leading to what?
Increased NE and Increased Angiotensin II which are meant to produce renal prostaglandin to compensate renal effects on vasoconstriction
36
If NSAIDs are utilized in a patient with CHF, volume contraction, and cirrhosis/ascites what would happen?
NSAIDs will inhibit renal prostaglandins leading to renal dysfunction
37
PGE2 and PGI2 lead to what?
Vasodilation
38
NSAIDs inhibit arachidonic acid transformation into prostaglandins, PGE2 and PGI2 which decreased prostaglandins leads to what?
1. Increased Creatinine
2. Edema/HTN
3. Hyperkalemia
4. Hyponatremia
39
What are the risk factors for NSAID nephrotoxicity with Cr > 2?
1. Age > 65 yrs
2. HTN
3. CHF
4. Diuretics
5. ACE Inhibitors
40
What NSAIDs have renal sparing effects?
1. Sulindac
2. Salsalate
41
Do COX-2 specific inhibitors, celecoxib spare kidneys?
NO
42
Which NSAID has the most effect renally?
Indomethacin
43
Which NSAID has the least effect renally?
Sulindac
44
What are the types of NSAID Nephrotoxicity?
1. Interstitial Nephritis
2. Nephrotic Syndrome
3. Analgesic Nephropathy
45
List all the possible renal effects NSAIDs cause that can lead to increased Creatinine?
1. Decreased renal blood flow
2. Decreased GFR
3. Increased BUN
46
List all the possible renal effects NSAIDs cause that can lead to increased Edema/HTN?
1. Increased chloride absorption
2. Sodium retention
47
List all the possible renal effects NSAIDs cause that can lead to increased Hyperkalemia?
1. Decreased renin
2. Decreased aldosterone
3. Potassium retention
48
List all the possible renal effects NSAIDs cause that can lead to increased Hyponatremia?
1. Increased ADH Effect
2. Water retention
49
What are the Hematologic Effects of NSAIDs?
1. Inhibition of platelet aggregation
2. Aplastic anemia
3. Agranulocytosis
4. Thrombocytopenia
50
COX 1 leads to Thromboxane which promotes what?
Platelet Aggregation
51
COX 2 leads to Prostacyclin which promotes what?
Inhibition of platelet aggregation
52
Celecoxib inhibits COX2, inhibiting Prostacyclin production leading to what?
1. NO inhibition of platelet aggregation
2. Production of Thromboxane
3. Promotion of platelet aggregation
4. Increased platelet aggregation = CV Events
53
Acute MI Risk was highest with what NSAID?
Indomethacin
54
In the Precision Trial, what NSAID was deemed NOT inferior in cardiac safety, but had LESS GI risk?
Celecoxib
55
What were the Hepatic Effects of NSAIDs?
1. Elevated Liver Enzymes
2. Fatal Hepatotoxicity
56
What NSAIDs are associated with hepatotoxicity?
1. Diclofenac
2. Sulindac
57
What are the risk factors for NSAID Hepatotoxicity?
1. Advanced age
2. Decreased renal function
3. Multiple drug use
4. High doses
5. Long duration of therapy
6. Juvenile arthritis, systemic lupus, RA
58
What are the CNS Effects of NSAIDs?
1. Tinnitus
2. Hearing loss
3. HA
4. Dizziness
5. Confusion aseptic menigitis
59
What are the Hypersensitivity Effects of NSAIDs?
Triad: asthma, ASA sensitivity, nasal polyps
60
What NSAIDs have Cutaneous Effects?
1. Piroxicam
2. Sulindac
3. Meclfenamate
61
What NSAIDs have possible teratogenicity?
ASA
Indomethacin
62
When should NSAIDs be avoided in pregnancy and what does it do?
AVOID in LATE pregnancy
1. Inhibit labor
2. Early narrowing of ductus arteriosus
63
What is the absorption of NSAIDs?
RAPID
64
What is the distribution of NSAIDs?
HIGHLY plasma protein bound
65
What is the metabolism of NSAIDs?
Main elimination route
66
What is the excretion of NSAIDs?
Minor Path <10%
67
What are the drugs that interact with NSAIDs?
1. Warfarin, other anticoagulants
2. Probenecid
3. Oral hypoglycemics
4. Methotrexate
5. Antihypertensives
6. Lithium
7. Diuretics
8. ASA/NSAIDs
68
What are the effects of Warfarin/Anticoagulants when combined with NSAIDs?
1. Increased Bleeding
2. GI Ulcerations
3. Protein binding displacement (warfarin)
4. Inhibition of metabolism (warfarin)
69
What NSAID do you choose when the patient is on Warfarin or Anticoagulant?
1. Celecoxib
2. Nonacetylated Salicylate
70
What are the effects of Probenecid when combined with NSAIDs?
1. Decreases NSAID secretion
2. Probenecid effects inhibited by ASA
71
What are the effects of Oral Hypoglycemics when combined with NSAIDs?
1. Protein binding displacement
2. Decreased glucose
72
What are the effects of Methotrexate when combined with NSAIDs?
1. Excretion inhibited by NSAIDs
2. Decreased renal function
73
What is the rank of Antihypertensives that have DDIs with NSAIDs?
Beta Blockers > Vasodilators > Diuretics
74
What NSAIDs specifically affect BP?
1. Indomethacin
2. Naproxen
3. Piroxicam
4. Diclofenac
75
There is a greater increased in BP effect seen in what type of patients when antihypertensives are combined with NSAIDs?
>65 yrs and HTN history
76
What NSAIDs decrease the clearance of Lithium?
1. Indomethacin
2. Diclofenac
3. Piroxicam
77
NSAIDs increase renal plasma flow, and which diuretics show to have greater effect?
Loop Diuretic > Thiazides
78
What should you monitor when on Potassium Sparing Diuretics and NSAIDs?
Increases in K+
79
When ASA is combined with Ibuprofen what happens?
Decreased cardioprotective effects
80
When ASA is combined with Celecoxib what happens?
Decreased GI benefits
81
Should you combine NSAIDs?
NO, increased side effects
82
Are systemic corticosteroids recommended in OA?
NO
83
What type of corticosteroids can be used in OA and how often?
Intraarticular
1. No more than every 4-6 months
2. Not on a regular schedule
3. Few weeks relief
84
Hyaluronates are approved for what?
Knee OA
85
What is the proposed MOA of Hyaluronates?
Increase synovial fluid viscoelasticity
86
What is Glucosamine and what is its MOA?
Nutraceutical, Increases glycosaminoglycans
87
What can Glucosamine do for the joint space and what is a possible side effect?
Decreased joint space narrowing and symptoms with glucosamine
May worsen insulin resistance
88
What is the GAIT and what is its results?
Glucosamine/Chondroitin Arthritis Intervention Trial
No important effect on joint space narrowing but less progression with moderate OA vs severe
89
What are examples of Nutraceuticals for OA supplement?
Glucosamine Sulfate HCl
Chondroitin Sulfate
Avocado Soybean
Collagen
90
What is the MOA of Avocado-Soybean?
Inhibits IL-1, inhibits cartilage breakdown and promotes repair
91
What are Topical Therapy options in OA?
1. Capsaicin
2. NSAIDs - Dicofenac
92
What is Capsaicin's MOA and counseling points?
Depletes substances P from sensory nerves
Must apply 3-4x/day and wash hands after use
93
Topical Diclofenac has what counseling points?
Avoid sun exposure
94
What is OTC Ibuprofen?
Motrin, Advil
95
What is OTC Naproxen Sodium?
Aleve
96
What is strongly recommended treatment for Hand, Knee, and Hip OA?
1. Exercise
2. Self-Efficacy and Self-Management
97
What is conditionally recommended treatment for Hand, Knee, and Hip OA?
1. Cognitive Behavioral Therapy
2. Acupuncture
3. Thermal Interventions
98
What is strongly recommended treatment for Knee and Hip OA?
1. Weight loss
2. Tai Chi, Cane
3. Tibiofemoral Brace (knee only)
99
What is conditionally recommended treatment for Knee and Hip OA?
1. Balance training
2. Yoga, Brace, Kinseotape, Radiofrequency stimulation (knee only)
100
What are strong avoided recommended treatment for Knee and Hip OA?
Transcutaneous electrical nerve stimulation
101
What are conditionally avoided recommended treatment for Knee and Hip OA?
1. Modified shoes, wedged insoles
2. Massage/Manual therapy
3. Pulsed vibration therapy (knee only)
102
What are strong recommended treatment for Hand OA?
First carpometacarpal CMC orthosis
103
What are conditionally recommended treatment for Hand OA?
1. First CMS kinesio
2. Joint orthosis
3. Paraffin
104
What are conditionally avoided recommended treatment for Hand OA?
Iontophoresis
105
What are strongly recommended pharmacologic treatment for Hand, Knee, and Hip?
Oral NSAIDs
106
What are conditionally recommended pharmacologic treatment for Hand, Knee, and Hip?
IA Glucocorticoids vs other injections, APAP, Duloxetine, and Tramadol
107
What are strongly not recommended pharmacologic treatment for Hand, Knee, and Hip?
Bisphosphonates, glucosamine, hydroxychloroquine, methotrexate, and biologics
108
What are conditionally not recommended pharmacologic treatment for Hand, Knee, and Hip?
Colchicine, nontramadol opioids, fish oil, and vitamin D
109
What are strongly recommended pharmacologic treatment for Knee and Hip?
IA Glucocorticoids
Topical NSAID (knee only)
110
What are conditionally recommended pharmacologic treatment for Knee and Hip?
Topical capsaicin
111
What are strongly not recommended pharmacologic treatment for Knee and Hip?
Chondroitin sulfate, plates-rich plasma, stem cell injection
IA hyaluronic acid (hip only)
112
What are conditionally not recommended pharmacologic treatment for Knee and Hip?
IA botulinum toxin, prolotherapy
IA hyaluronic acid (knee only)
113
What are conditionally recommended pharmacologic treatment of the Hand?
Topical NSAID, IA Glucocorticoids, Chondroitin sulfate
114
What are conditionally not recommended pharmacologic treatment of the Hand?
Topical capsaicin, first CMC IA hyaluronic acid
