Week 9 MSK rheum falls Flashcards
Patho of osteoporosis
function of osteoblasts and osteoclasts
resorption of old bone (osteoclasts)
formation of new bone (osteoblasts)
Physical exam findings in osteoporosis:
- height
- rib-pelvis distance
- inability to….
- height loss >4 cm
- rib-pelvis distance <2 finger-breadths
- inability to touch occiput to wall when standing with heels to wall
decreased rib-pelvis distance is suggestive of….
occult vertebral fracture
what is the risk of prolonged bisphosphonate use?
osteonecrosis of jaw
atypical femoral fracture (subtrochanter, diaphysis of femur)
what is the max duration of treatment with bisphosphonates?
po: 5 years
IV: 3 years
LIFESTYLE risk factors for osteoporosis?
Smoking (current or former) Daily ETOH > 3 units Caffeine > 4 cups/day Inadequate calcium and vitamin D intake Lack of sunlight exposure Prolonged immobility and lack of weight-bearing exercise
MEDICAL risk factors for osteoporosis?
specific
for women?
for men?
Advanced age Frailty Hyperthyroidism (including iatrogenic) or hyperparathyroidism Celiac and other malabsorption syndromes BMI < 20 kg/m2 or weight loss Medication history, particularly chronic glucocorticoid use** Rheumatoid arthritis Chronic liver or kidney disease
For men: Androgen deficiency (primary or secondary)
For women:
Estrogen deficiency (primary or secondary)
Early menopause (< 45 years)
Cessation of menstruation for 6-12 consecutive months (excluding pregnancy, menopause or hysterectomy)
what is a fragility fracture?
common locations?
Fractures sustained in falls from standing height or less, in which bone damage is disproportional to the degree of trauma. Includes vertebral compression fractures not attributable to previous major trauma, which may be suggested by height loss.
Fractures of the hip, vertebra, humerus, and wrist are most closely associated with OP and increased future fracture risk whereas those of the skull, fingers, toes, and patella fractures are not.
when is BMD indicated? (BC Guidelines)
men and women age > 65 years
at moderate risk of fracture (10 - 20% 10-year risk),
and results are likely to alter patient care
T-score cut off
normal:
osteopenia:
osteoporosis:
severe osteoporosis:
Normal: T is -1 and above
Osteopenia: T is -1.1 to -2.4
Osteoporosis: T -2.5 and below
Established or severe OP: T is -2.5 or below and one or more prevalent low-trauma fractures
what is first line treatment for OP for those at high risk of falling?
Falls in the past year
Time taken to stand from sitting
Muscle strength, balance, and gait by watching the patient walk and move
Check and correct postural hypotension and cardiac arrhythmias
Evaluate any neurological problems
Review prescription meds that may affect balance
Provide a checklist for improving safety at home
what individuals are automatically considered high risk of OP without doing FRAX
-hip and fragility fracture
follow up of osteoporosis: when to repeat BMD?
- if not on OP meds?
- if on OP meds?
BC Guidelines: if not on OP meds, may retest in 3-10 years based on risk profile
If on OP meds, repeat BMD not justified (hard to detect changes on BMD prior to 3 years) unless specific high risk (eg on prednisone dose >7.5 mg daily for 3 consecutive months etc)
If repeat BMD is done: do on same DXA machine at same time of year
bisphosphonates:
- patient teaching
- contraindications
- side effects
Administration: swallow whole with full glass of water 30 min before first food of day; patients must not lie down for at least 30 min after dose
To enhance absorption and decrease gastrointestinal side effects emphasize proper administration
-po: available as 10 mg once daily or 70 mg once weekly
Contraindications: renal impairment [i.e., CrCl < 30 mL/min], hypocalcemia
Precautions: upper gastrointestinal problems
Adverse effects: abdominal pain, dyspepsia, nausea, esophagitis, esophageal ulcers, joint/muscle pain [may
need to discontinue if persists], ocular inflammation, osteonecrosis of the jaw (ONJ) atypical femoral fractures [although rare, seems to be more common with long term bisphosphonate use and can present as thigh or groin
pain], esophageal cancer, afib
Denosumab (prolia)
- route
- contraindications
- side effects
Administration: subcutaneous injection into the upper arm, upper thigh, or abdomen q6 months
Contraindications: hypocalcemia
Adverse effects: cellulitis, dermatitis, eczema, rashes, pancreatitis, osteonecrosis of the jaw (rare)
Osteoarthritis
risk factors
- Increasing age (55+)
- F more commonly affected, greater severity
- Genetics
- Trauma: previous #, ligamentous injury
- Obesity
- inflammation from infection, inflammatory arthropathies, metabolic disorders
Rheumatoid arthritis
risk factors
- Bimodal age distribution (30s, 70s)
- F
- Genetics: family hx
- Smoking
- Periodontal disease
- systemic illness/trauma
Onset of OA vs RA
OA: worse as day goes on, worse with activity
RA: morning stiffness
OA vs RA
affected joints and associated deformities
OA: hands, knees, hips, neck, back.
deformities: Bouchard’s (PIP), Heberden’s (DIP)
RA: peripheral joints (late onset proximal joints)
fingers, elbows, shoulders, ankles, knees, toes
PIP: boutonniere deformities, swan-neck contractures, ulnar deviation
OA vs RA
pain characteristics
OA:
Sharp/aching unilateral joint pain
Morning stiffness <30 min
Worse with activity
RA:Symmetrical
Morning stiffness >30 min
Accompanied by swelling and warmth in 3+ joints
Rheumatoid arthritis
extra-articular manifestations
Systemic symptoms: fatigue, malaise, low grade fever, weight loss, depression
Anemia, pleuropericarditis, neuropathy, myopathy, splenomegaly, Sjogren’s, scleritis, vasculitis, renal disease, carpel tunnel syndrome
Increased risk of OP #
Labwork. OA vs RA
OA: neg CRP, RF, ANA
RA: reactive CRP, RF and anti-CCP may be positive
Management of OA
Exercise and strengthening Weight loss Pain relief: • Acetaminophen up to 1 g QID first line • NSAIDs if tylenol ineffective ○ Naproxen 220-385 mg OD-BID PRN ○ Limit to 2-4 weeks max effect ○ Celebrex 200 mg OD-BID PRN • H2RA for gastritis and PUD protection • Topical voltaren ○ Preferred over po NSAIDs for those >75+ • Capsaicin Intra-articular injections: Avoid >3-4x/year
Management of RA
EARLY DETECTION to start DMARDs by rheum Exercise and joint mobility Smoking cessation DMARDS first line, start ASAP • MTX weekly first line • Sulfasalazine 500-1000 mg daily • Hydroxychloroquine 200-400 mg daily Pain relief: • NSAIDs ○ Ibuprofen 600-800 mg q6-8h PRN ○ Naproxen 500 mg q12h PRN • Prednisone for active joint inflammation ○ Short course recommended Intra-articular injections to reduce synovitis
OA
Hallmark pathology:
Xray findings
Hallmark: cartilage loss
Xray:
Joint space narrowing
osteophytes
subchondral sclerosis
RA
Hallmark pathology
Xray findings:
Hallmark: synovial inflammation extending to cartilage
Xray: Osteopenia joint space narrowing bone erosions Loss of articular space ulnar deviation
why is folate supplementation needed with methotrexate?
Folic acid supplementation during methotrexate therapy can reduce the risks of adverse effects including nausea, vomiting, abdominal pain, mouth ulcers, raised liver enzymes and bone marrow toxicity
what are two major ADE associated with hydroxychloroquine (Plaquenil)?
- retinopathy–> needs annual ophtho (q6-12 months)
- rash (rare but SJS and TENs can occur)
biologics for RA
before starting, important to check for which infections?
Screen for TB, hep B, hep C
**biologics can reactivate
**also ensure immunizations up to date
what is the most important risk factor for pseudogout (CPPD)?
other risk factors?
advanced age
-phosphate, Mg, parathyroid and thyroid disorders, hemochromatosis
All patients with PMR should be screened for….?
Giant cell arteritis
PMR
symptoms? timing?
joints affected?
acute onset ache and MORNING STIFFNESS
timing: worse in AM, lasts >1 hour
IMPROVES with activity, WORSEN with inactivity
duration: >2 weeks
joints: shoulders and/or hip girdle BILATERAL
may have fever, malaise, fatigue, decreased ADLs
also ask re: symptoms of GCA
GCA symptoms
headache
jaw claudication
***visual disturbances
fever, weight loss, and fatigue
PMR
labwork
CRP elevated
CK normal
RF and anti-CCP negative
PMR
imaging
ultrasound: bursitis, tenosynovitis, synovitis
PMR treatment
prednisone 12.5-25 mg daily
-depends on comorbidities eg brittle diabetic, frail
reassess in 1-2 weeks
recheck CRP in 4-6 weeks
often on steroids for long term before attempting taper consider OP protection
