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GI/Rheumatology Module > Osteoarthritis Treatment > Flashcards

Osteoarthritis Treatment Flashcards

1
Q

What are the OA Assessment Instruments?

A
  1. WOMAC OA Index
  2. Lequesne Index
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2
Q

What does the WOMAC OA Index assess?

A
  1. Pain, stiffness
  2. Physical, social, emotional function
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3
Q

What does the Lequesne Index assess?

A
  1. Pain/Discomfort
  2. Maximum distance walked
  3. Activities of daily living
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4
Q

What are the Non-Drug Treatment options for OA?

A
  1. Patient Education
  2. Self-Management Programs
  3. Association between alcohol intake and OA severity
  4. Social Support
  5. Diet
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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

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6
Q

Which dietary supplement inhibits the arachidonic acid pathway?

A

Fish Oil

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7
Q

Which dietary supplement inhibits arachidonic acid?

A

Evening primrose oil

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8
Q

What is a non-drug treatment option that is very important in OA?

A

Physical/Occupational Therapy

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9
Q

What are things to consider under Physical/Occupational Therapy?

A
  1. Exercise: low impact
  2. Assistive Devices
  3. Joint Protection
  4. Heat or Cold
  5. Paraffin
  6. TENS
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10
Q

What is the goal in the treatment of OA?

A

Relieve pain, and preserve function

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11
Q

What are the analgesics that can be used in the treatment of OA?

A
  1. Acetaminophen
  2. Salicylate, NSAIDs
  3. Opioids, Codeine
  4. Tramadol
  5. Duloxetine
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12
Q

What is the dosing for APAP in OA?

A

650 mg/dose, 3250 mg/day

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13
Q

What is the dosing for APAP in OA patient with liver disease?

A

<2000 mg/dose

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14
Q

What is the dosing schedule for APAP in OA?

A

PRN

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15
Q

Which Analgesic has limited effectiveness in OA?

A

APAP

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16
Q

Opioids and Codeine are not recommended in elderly due to what?

A

Increased fall and fracture risk

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17
Q

Which analgesic used in OA can lead to QT Prolongation and Serotonin Syndrome?

A

Tramadol

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18
Q

What analgesic is most useful in OA with depression or widespread pain?

A

Duloxetine

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19
Q

What is the analgesic dose of ASA?

A

325-640 QID

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20
Q

ALL NSAID effect is on what?

A

Cyclooxygenase

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21
Q

Which analgesic have an irreversible effect on COX?

A

ASA

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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

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23
Q

What is the function of COX-2?

A

Increases inflammation
1. Regulate prostacyclin

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24
Q

Which drug is a Selective COX-2 Inhibitor?

A

Celecoxib/Celebrex

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25
Q

Do NSAIDs affect lipoxygenase pathway?

A

NO

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26
Q

What are the effects of NSAIDs?

A
  1. Anti-Inflammatory
  2. Analgesic
  3. Antipyretic
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27
Q

What is considered more effective than APAP in OA?

A

NSAIDs

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28
Q

What are the MAJOR side effects of NSAIDs?

A
  1. Gastrointestinal
  2. Renal
  3. Hematologic
  4. Cardiovascular
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29
Q

Where is the Primary Insult of NSAIDs?

A

Direct Acid Damage

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30
Q

What is the Secondary Insult of NSAIDs?

A

Prostaglandin Inhibition, systemic effect

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31
Q

What are 3 steps in preventing NSAID Esophageal Injury?

A
  1. Upright Position
  2. Sufficient Liquid >120 mL
  3. Not immediately before bedtime
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32
Q

What can be used to prevent NSAID Ulcers?

A

Proton Pump Inhibitors PPI, decrease risk and promote healing

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33
Q

What is an alternative to PPI in prevention of NSAID Ulcers?

A

Misoprostol

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34
Q

What is the problem with Misoprostol?

A
  1. High incidence of GI side effects
  2. CI in pregnancy
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35
Q

In patients with CHF, volume contraction, and cirrhosis/ascites, they have increased adrenergic and renin-angiotensin systems leading to what?

A

Increased NE and Increased Angiotensin II which are meant to produce renal prostaglandin to compensate renal effects on vasoconstriction

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36
Q

If NSAIDs are utilized in a patient with CHF, volume contraction, and cirrhosis/ascites what would happen?

A

NSAIDs will inhibit renal prostaglandins leading to renal dysfunction

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37
Q

PGE2 and PGI2 lead to what?

A

Vasodilation

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38
Q

NSAIDs inhibit arachidonic acid transformation into prostaglandins, PGE2 and PGI2 which decreased prostaglandins leads to what?

A
  1. Increased Creatinine
  2. Edema/HTN
  3. Hyperkalemia
  4. Hyponatremia
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39
Q

What are the risk factors for NSAID nephrotoxicity with Cr > 2?

A
  1. Age > 65 yrs
  2. HTN
  3. CHF
  4. Diuretics
  5. ACE Inhibitors
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40
Q

What NSAIDs have renal sparing effects?

A
  1. Sulindac
  2. Salsalate
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41
Q

Do COX-2 specific inhibitors, celecoxib spare kidneys?

A

NO

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42
Q

Which NSAID has the most effect renally?

A

Indomethacin

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43
Q

Which NSAID has the least effect renally?

A

Sulindac

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44
Q

What are the types of NSAID Nephrotoxicity?

A
  1. Interstitial Nephritis
  2. Nephrotic Syndrome
  3. Analgesic Nephropathy
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45
Q

List all the possible renal effects NSAIDs cause that can lead to increased Creatinine?

A
  1. Decreased renal blood flow
  2. Decreased GFR
  3. Increased BUN
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46
Q

List all the possible renal effects NSAIDs cause that can lead to increased Edema/HTN?

A
  1. Increased chloride absorption
  2. Sodium retention
47
Q

List all the possible renal effects NSAIDs cause that can lead to increased Hyperkalemia?

A
  1. Decreased renin
  2. Decreased aldosterone
  3. Potassium retention
48
Q

List all the possible renal effects NSAIDs cause that can lead to increased Hyponatremia?

A
  1. Increased ADH Effect
  2. Water retention
49
Q

What are the Hematologic Effects of NSAIDs?

A
  1. Inhibition of platelet aggregation
  2. Aplastic anemia
  3. Agranulocytosis
  4. Thrombocytopenia
50
Q

COX 1 leads to Thromboxane which promotes what?

A

Platelet Aggregation

51
Q

COX 2 leads to Prostacyclin which promotes what?

A

Inhibition of platelet aggregation

52
Q

Celecoxib inhibits COX2, inhibiting Prostacyclin production leading to what?

A
  1. NO inhibition of platelet aggregation
  2. Production of Thromboxane
  3. Promotion of platelet aggregation
  4. Increased platelet aggregation = CV Events
53
Q

Acute MI Risk was highest with what NSAID?

A

Indomethacin

54
Q

In the Precision Trial, what NSAID was deemed NOT inferior in cardiac safety, but had LESS GI risk?

A

Celecoxib

55
Q

What were the Hepatic Effects of NSAIDs?

A
  1. Elevated Liver Enzymes
  2. Fatal Hepatotoxicity
56
Q

What NSAIDs are associated with hepatotoxicity?

A
  1. Diclofenac
  2. Sulindac
57
Q

What are the risk factors for NSAID Hepatotoxicity?

A
  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
Q

What are the CNS Effects of NSAIDs?

A
  1. Tinnitus
  2. Hearing loss
  3. HA
  4. Dizziness
  5. Confusion aseptic menigitis
59
Q

What are the Hypersensitivity Effects of NSAIDs?

A

Triad: asthma, ASA sensitivity, nasal polyps

60
Q

What NSAIDs have Cutaneous Effects?

A
  1. Piroxicam
  2. Sulindac
  3. Meclfenamate
61
Q

What NSAIDs have possible teratogenicity?

A

ASA
Indomethacin

62
Q

When should NSAIDs be avoided in pregnancy and what does it do?

A

AVOID in LATE pregnancy
1. Inhibit labor
2. Early narrowing of ductus arteriosus

63
Q

What is the absorption of NSAIDs?

A

RAPID

64
Q

What is the distribution of NSAIDs?

A

HIGHLY plasma protein bound

65
Q

What is the metabolism of NSAIDs?

A

Main elimination route

66
Q

What is the excretion of NSAIDs?

A

Minor Path <10%

67
Q

What are the drugs that interact with NSAIDs?

A
  1. Warfarin, other anticoagulants
  2. Probenecid
  3. Oral hypoglycemics
  4. Methotrexate
  5. Antihypertensives
  6. Lithium
  7. Diuretics
  8. ASA/NSAIDs
68
Q

What are the effects of Warfarin/Anticoagulants when combined with NSAIDs?

A
  1. Increased Bleeding
  2. GI Ulcerations
  3. Protein binding displacement (warfarin)
  4. Inhibition of metabolism (warfarin)
69
Q

What NSAID do you choose when the patient is on Warfarin or Anticoagulant?

A
  1. Celecoxib
  2. Nonacetylated Salicylate
70
Q

What are the effects of Probenecid when combined with NSAIDs?

A
  1. Decreases NSAID secretion
  2. Probenecid effects inhibited by ASA
71
Q

What are the effects of Oral Hypoglycemics when combined with NSAIDs?

A
  1. Protein binding displacement
  2. Decreased glucose
72
Q

What are the effects of Methotrexate when combined with NSAIDs?

A
  1. Excretion inhibited by NSAIDs
  2. Decreased renal function
73
Q

What is the rank of Antihypertensives that have DDIs with NSAIDs?

A

Beta Blockers > Vasodilators > Diuretics

74
Q

What NSAIDs specifically affect BP?

A
  1. Indomethacin
  2. Naproxen
  3. Piroxicam
  4. Diclofenac
75
Q

There is a greater increased in BP effect seen in what type of patients when antihypertensives are combined with NSAIDs?

A

> 65 yrs and HTN history

76
Q

What NSAIDs decrease the clearance of Lithium?

A
  1. Indomethacin
  2. Diclofenac
  3. Piroxicam
77
Q

NSAIDs increase renal plasma flow, and which diuretics show to have greater effect?

A

Loop Diuretic > Thiazides

78
Q

What should you monitor when on Potassium Sparing Diuretics and NSAIDs?

A

Increases in K+

79
Q

When ASA is combined with Ibuprofen what happens?

A

Decreased cardioprotective effects

80
Q

When ASA is combined with Celecoxib what happens?

A

Decreased GI benefits

81
Q

Should you combine NSAIDs?

A

NO, increased side effects

82
Q

Are systemic corticosteroids recommended in OA?

A

NO

83
Q

What type of corticosteroids can be used in OA and how often?

A

Intraarticular
1. No more than every 4-6 months
2. Not on a regular schedule
3. Few weeks relief

84
Q

Hyaluronates are approved for what?

A

Knee OA

85
Q

What is the proposed MOA of Hyaluronates?

A

Increase synovial fluid viscoelasticity

86
Q

What is Glucosamine and what is its MOA?

A

Nutraceutical, Increases glycosaminoglycans

87
Q

What can Glucosamine do for the joint space and what is a possible side effect?

A

Decreased joint space narrowing and symptoms with glucosamine
May worsen insulin resistance

88
Q

What is the GAIT and what is its results?

A

Glucosamine/Chondroitin Arthritis Intervention Trial
No important effect on joint space narrowing but less progression with moderate OA vs severe

89
Q

What are examples of Nutraceuticals for OA supplement?

A

Glucosamine Sulfate HCl
Chondroitin Sulfate
Avocado Soybean
Collagen

90
Q

What is the MOA of Avocado-Soybean?

A

Inhibits IL-1, inhibits cartilage breakdown and promotes repair

91
Q

What are Topical Therapy options in OA?

A
  1. Capsaicin
  2. NSAIDs - Dicofenac
92
Q

What is Capsaicin’s MOA and counseling points?

A

Depletes substances P from sensory nerves
Must apply 3-4x/day and wash hands after use

93
Q

Topical Diclofenac has what counseling points?

A

Avoid sun exposure

94
Q

What is OTC Ibuprofen?

A

Motrin, Advil

95
Q

What is OTC Naproxen Sodium?

A

Aleve

96
Q

What is strongly recommended treatment for Hand, Knee, and Hip OA?

A
  1. Exercise
  2. Self-Efficacy and Self-Management
97
Q

What is conditionally recommended treatment for Hand, Knee, and Hip OA?

A
  1. Cognitive Behavioral Therapy
  2. Acupuncture
  3. Thermal Interventions
98
Q

What is strongly recommended treatment for Knee and Hip OA?

A
  1. Weight loss
  2. Tai Chi, Cane
  3. Tibiofemoral Brace (knee only)
99
Q

What is conditionally recommended treatment for Knee and Hip OA?

A
  1. Balance training
  2. Yoga, Brace, Kinseotape, Radiofrequency stimulation (knee only)
100
Q

What are strong avoided recommended treatment for Knee and Hip OA?

A

Transcutaneous electrical nerve stimulation

101
Q

What are conditionally avoided recommended treatment for Knee and Hip OA?

A
  1. Modified shoes, wedged insoles
  2. Massage/Manual therapy
  3. Pulsed vibration therapy (knee only)
102
Q

What are strong recommended treatment for Hand OA?

A

First carpometacarpal CMC orthosis

103
Q

What are conditionally recommended treatment for Hand OA?

A
  1. First CMS kinesio
  2. Joint orthosis
  3. Paraffin
104
Q

What are conditionally avoided recommended treatment for Hand OA?

A

Iontophoresis

105
Q

What are strongly recommended pharmacologic treatment for Hand, Knee, and Hip?

A

Oral NSAIDs

106
Q

What are conditionally recommended pharmacologic treatment for Hand, Knee, and Hip?

A

IA Glucocorticoids vs other injections, APAP, Duloxetine, and Tramadol

107
Q

What are strongly not recommended pharmacologic treatment for Hand, Knee, and Hip?

A

Bisphosphonates, glucosamine, hydroxychloroquine, methotrexate, and biologics

108
Q

What are conditionally not recommended pharmacologic treatment for Hand, Knee, and Hip?

A

Colchicine, nontramadol opioids, fish oil, and vitamin D

109
Q

What are strongly recommended pharmacologic treatment for Knee and Hip?

A

IA Glucocorticoids
Topical NSAID (knee only)

110
Q

What are conditionally recommended pharmacologic treatment for Knee and Hip?

A

Topical capsaicin

111
Q

What are strongly not recommended pharmacologic treatment for Knee and Hip?

A

Chondroitin sulfate, plates-rich plasma, stem cell injection
IA hyaluronic acid (hip only)

112
Q

What are conditionally not recommended pharmacologic treatment for Knee and Hip?

A

IA botulinum toxin, prolotherapy
IA hyaluronic acid (knee only)

113
Q

What are conditionally recommended pharmacologic treatment of the Hand?

A

Topical NSAID, IA Glucocorticoids, Chondroitin sulfate

114
Q

What are conditionally not recommended pharmacologic treatment of the Hand?

A

Topical capsaicin, first CMC IA hyaluronic acid

GI/Rheumatology Module (18 decks)

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