Osteoarthritis Case Study and Treatment Plans
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Questions and Answers

What is a common clinical presentation of osteoarthritis as observed in the case study?

  • Severe joint redness and warmth
  • Morning stiffness in both knees (correct)
  • Persistent swelling in the knee
  • Complete loss of joint mobility

    • Which mechanism contributes to the pathophysiology of osteoarthritis?

  • Cartilage degradation and joint space narrowing (correct)
  • Increased synovial fluid production
  • Autoimmune destruction of synovial tissue
  • Formation of new bone at joint margins

    • What is indicated by the varus misalignment of the knee observed in the physical examination?

  • Distal knee portion angles outward from the midline
  • Distal knee portion angles inward toward the midline (correct)
  • Weakness in the surrounding muscles
  • Increased lateral stability of the knee joint

    • Which assessment tool is utilized to determine the severity of pain in patients with osteoarthritis?

    <p>Numeric Pain Rating Scale</p> Signup and view all the answers

    Which medication is NOT listed in the patient's current medications for managing osteoarthritis symptoms?

    <p>Acetaminophen</p> Signup and view all the answers

    Which finding on the radiograph is consistent with osteoarthritis?

    <p>Osteophyte formation</p> Signup and view all the answers

    What is the significance of crepitus noted during the examination of the knee?

    <p>May indicate joint surface irregularities</p> Signup and view all the answers

    Which factor is NOT typically associated with an increased risk of developing osteoarthritis?

    <p>Regular physical activity</p> Signup and view all the answers

    What is the primary goal of drug therapy for osteoarthritis?

    <p>Relieve pain and stiffness</p> Signup and view all the answers

    Which of the following is considered a first line treatment among NSAIDs for osteoarthritis?

    <p>Oral NSAIDs</p> Signup and view all the answers

    In the context of assessing safety for NSAID treatment, which factor should be monitored periodically?

    <p>Renal function and blood pressure</p> Signup and view all the answers

    What is a common nonpharmacologic therapy suggested for osteoarthritis management?

    <p>Self-care and education</p> Signup and view all the answers

    Which of the following medications is conditionally recommended against for hip osteoarthritis based on the guideline?

    <p>Chondroitin sulfate</p> Signup and view all the answers

    What typical symptom should patients on NSAIDs be monitored for indicating potential gastrointestinal bleeding?

    <p>Black or tarry stools</p> Signup and view all the answers

    For which of the following populations should NSAID use be approached with caution due to increased risks?

    <p>Patients over 75 years</p> Signup and view all the answers

    Which therapeutic exercise is specifically mentioned as more effective when supervised?

    <p>Tai chi</p> Signup and view all the answers

    What is one of the primary considerations when using analgesics at lower doses?

    <p>The lowest effective dose should be used.</p> Signup and view all the answers

    What non-drug therapy might improve joint stability and mobility?

    <p>Muscle strengthening exercises</p> Signup and view all the answers

    What is the maximum recommended daily dosage of duloxetine for patients without liver disease or alcohol use?

    <p>60 mg</p> Signup and view all the answers

    In patients with contraindicated sulfonamide allergies, which medication should not be prescribed?

    <p>Celecoxib</p> Signup and view all the answers

    Which of the following is a major advantage of using the specified OTC pain reliever?

    <p>It is devoid of gastrointestinal and cardiovascular toxicity</p> Signup and view all the answers

    For a patient with chronic musculoskeletal pain and no previous history of GI issues, which NSAID is likely the safest option given a high cardiovascular risk?

    <p>Naproxen</p> Signup and view all the answers

    What is the appropriate tapering duration for discontinuing duloxetine?

    <p>2-4 weeks</p> Signup and view all the answers

    Which of the following is a potential risk associated with increased dosage of duloxetine above the label recommendation?

    <p>Increased adverse effects</p> Signup and view all the answers

    What effect do NSAIDs generally have concerning antiplatelet activity when used with aspirin (ASA)?

    <p>Interfere with aspirin's activity</p> Signup and view all the answers

    Which of the following best describes the contraindications for the use of Diclofenac in the setting of CABG surgery?

    <p>It is contraindicated for treating peri-operative pain.</p> Signup and view all the answers

    What is the maximum daily dose of Diclofenac for the lower extremity?

    <p>32 g</p> Signup and view all the answers

    What is a key instruction to be followed after applying topical Diclofenac?

    <p>Avoid exposing the area to sunlight.</p> Signup and view all the answers

    Which caution should be observed when using Diclofenac for topical application?

    <p>Avoid using with other topical NSAIDs in the same location.</p> Signup and view all the answers

    How long may it take for Diclofenac gel to produce noticeable effects?

    <p>Approximately 7 days.</p> Signup and view all the answers

    Elderly patients using NSAIDs such as Diclofenac are at greater risk of which adverse effect?

    <p>Serious gastrointestinal events.</p> Signup and view all the answers

    Which of the following best describes the frequency of application for Diclofenac gel in lower extremities?

    <p>Four times daily</p> Signup and view all the answers

    Why is topical Diclofenac considered to have safety concerns similar to oral NSAIDs?

    <p>It is absorbed systemically.</p> Signup and view all the answers

    What amount of topical solution (Pennsaid) should be applied to each knee?

    <p>40 mg</p> Signup and view all the answers

    Which of the following conditions is a contraindication for the use of Diclofenac?

    <p>History of allergic reactions to aspirin or other NSAIDs</p> Signup and view all the answers

    Which of the following is a warning associated with the use of medications following CABG surgery?

    <p>Cardiovascular thrombotic events</p> Signup and view all the answers

    What risk is associated with the use of topical NSAIDs like Diclofenac?

    <p>Less gastrointestinal adverse effects than oral NSAIDs</p> Signup and view all the answers

    Intraarticular glucocorticoids should not be administered more frequently than:

    <p>Every 3 months</p> Signup and view all the answers

    What potential side effect is specifically mentioned for intraarticular glucocorticoid injection?

    <p>Hyperglycemia, especially in diabetics</p> Signup and view all the answers

    What is the maximum recommended daily dosage of Acetaminophen?

    <p>4000 mg</p> Signup and view all the answers

    What is the estimated systemic absorption percentage of topical NSAIDs like Diclofenac?

    <p>1-15%</p> Signup and view all the answers

    What is a possible outcome of aspiration of joint effusion in the context of intraarticular glucocorticoid treatment?

    <p>Placebo effect</p> Signup and view all the answers

    What is a conditionally recommended use of Acetaminophen?

    <p>Knee pain</p> Signup and view all the answers

    Which of the following represents a serious risk concerning fetal health when using medications after 29 weeks of pregnancy?

    <p>Premature closure of the fetal ductus arteriosus</p> Signup and view all the answers

    Which side effect is noted for topical NSAIDs like Diclofenac?

    <p>Local skin reaction – itching or rash</p> Signup and view all the answers

    Study Notes

    Osteoarthritis

    • Osteoarthritis is a condition affecting the movable, synovial-lined joints, characterized by degenerative and inflammatory processes.
    • It's a common cause of joint disability, pain, and altered joint function.
    • The presentation of osteoarthritis varies significantly between individuals.
    • Students will learn about its pathophysiology, epidemiology, clinical presentation, and risk factors related to osteoarthritis.
    • They will be able to create a treatment plan for osteoarthritis, encompassing non-drug measures, and the mechanism, toxicity, interactions, and clinical use of relevant medications.
    • Patient education and pharmaceutical care relating to osteoarthritis will also be discussed.

    Case Study (YJ)

    • YJ, a 60-year-old female, weighing 205 lbs, has osteoarthritis affecting her right knee (1 year).
    • She experiences intermittent pain in her right knee, alongside morning stiffness in both knees, exacerbated by activity.
    • Notably, she has a negative history of tobacco and alcohol use.

    Pain Assessment

    • Pain is measured on a scale of 0-10, with 0 denoting no pain and 10 being the most severe imaginable pain.
    • Mild pain ranges from 1 to 3.
    • Moderate pain from 4 to 6.
    • Severe pain from 7 to 10.

    Current Medications

    • Amlodipine 5 mg daily
    • Levothyroxine 88 mcg daily
    • Simvastatin 40 mg daily
    • No known drug allergies (NKDA)

    Physical Examination (PE)

    • Physical examination (PE) reveals varus misalignment of the right knee, without swelling or synovial effusion.
    • Crepitus is noted during physical examination.

    Radiographic Findings

    • Radiographic images reveal narrowing of the right knee joint space.
    • Osteophyte formation is present at the joint margins.

    Laboratory Findings (Labs)

    • BP: 135/78, HR: 80 BPM, Ht: 64 in, Wt: 205 lb, BMI: 35.2 kg/m².
    • Relevant lab values include:
      • Sodium: 140 mEq/L
      • Potassium: 4.5 mEq/L
      • BUN: 10 mg/dL
      • Creatinine: 0.9 mg/dL
      • eGFR: 63 mL/min
      • WBC: 5 x 10³/μL
      • RBC: 4.7 x 10⁶/μL
      • Hemoglobin: 12.7 g/dL
      • Hematocrit: 38.2%
      • TSH: 3.08 mIU/mL
      • Uric acid: 5 mg/dL
      • CRP: 0.9 mg/dL
      • ESR: 18 mm/hour
      • Anti-CCP antibodies: negative
      • RF: negative
      • Total cholesterol: 160 mg/dL
      • HDL: 35 mg/dL

    Epidemiology

    • 32.5 million US adults have osteoarthritis, one out of seven.
    • 18.7 million are aged 18-64, exceeding 1.5 million.
    • OA is associated with aging, and overlaps with other chronic conditions.
    • $4,274 less in earnings annually due to OA in the US.
    • Cost of medical care for OA in the US is $71.3 billion.
    • $2.018 in annual medical costs per year.
    • OA related cost in the US is $65.5 billion.

    Risk Factors

    • Age (1.6% between 30-39 and 14% for those over 85).
    • Obesity (35% increase in risk per 5 unit increase in BMI).
    • Genetic factors (account for approximately 30% of risk factors).
    • Sex (Heberden's nodes are 10x more common in women than men).
    • Joint Trauma (sports and accidents)
    • Repetitive Stress (Sports and occupational factors)

    Key Features

    • Failure of the movable, synovial-lined joint.
    • Degenerative and inflammatory processes.
    • Common cause of disability and pain.
    • Altered joint function.
    • Highly variable presentation.

    Cartilage Damage

    • Chondrocytes strive to repair damage.
    • The structure of collagen fibers within the extracellular matrix shows alteration.
    • Chondrocytes experience a reduced ability to maintain a balance between disintegration and rebuilding, often exhibiting increased apoptosis.
    • Cartilage loss results in joint space narrowing.

    Impaired Joint

    • Vertical clefts develop but function remains below par.
    • Growth of bone structures (osteophytes or bone spurs) modifies joint contour.
    • Reduced joint mobility.
    • Synovitis leads to thickening of the joint capsule.
    • Periarticular muscle wasting is a common finding

    Joint Involvement by Osteoarthritis

    • Joints affected by osteoarthritis encompass a range of sites, including but not limited to:
      • Knees
      • Hips
      • Cervical and Lumbar Spine
      • Distal Interphalangeal Joints
      • Proximal Interphalangeal Joints
      • First Carpometacarpal (thumb base)
      • First Metatarsal Phalangeal (big toe)
      • Shoulder
      • Elbow
      • Wrist
      • Ankle
      • Metacarpal Phalangeal

    Hands in Osteoarthritis

    • Identifying features of osteoarthritis in the hands include:
      • Heberden's nodes (distal interphalangeal joints)
      • Bouchard's nodes (proximal interphalangeal joints)
      • Small, fixed bumps (nodes)
      • Calcified spurs in articular cartilage Pain in Osteoarthritis
    • Cartilage lacks significant nerve endings.
    • Pain emanates from sources including:
      • Osteophyte growth impacting the periosteum
      • Microfractures
      • Synovitis
      • Ligament/meniscus damage

    Principles of Drug Therapy

    • Non-pharmacological therapy is a first-line approach for osteoarthritis management.
    • Medications do not substantially alter the course of the disease but provide symptomatic relief.
    • Self-care is appropriate if the condition is diagnosed.
    • Treatment objectives include:
      • Pain and stiffness alleviation
      • Maintaining or improving joint mobility and functionality.
      • Limiting functional impairment.
      • Improving quality of life.
      • Minimizing medication adverse effects.

    Monitoring

    • Efficacy: Assessing how well treatment works. How soon does each therapy demonstrate a benefit from daily pain logs or other quality of life questionnaires.
    • Safety: Determining treatment safety. Potential toxicity of treatment must be evaluated.

    Non-drug Therapy

    • Patient education.
    • Exercise.
    • Weight loss.
    • Muscle Strengthening Exercises
    • Tai Chi
    • Cane Use
    • Knee brace.
    • Orthotics (support for the first carpometacarpal joint).

    Physical and Occupational Therapy

    • Supervised exercise programs are crucial.
    • Self-efficacy and self-management skills are vital.
    • Joint stability, mobility, and range-of-motion improvement.
    • Utilizing adaptive devices like canes and walkers.
    • Prescribing exercises to promote joint protection and energy conservation for daily living activities and assistive devices.

    Assistive Devices

    • Specific aids to help with activities of daily living (ADL).

    Osteoarthritis Guideline

    • A comprehensive guideline for managing osteoarthritis, outlining evidence-based recommendations from the American College of Rheumatology and the Arthritis Foundation.

    Over-the-Counter Analgesics

    • Different analgesics and their dosage and frequency.
    • Specific details on different pain relievers to treat the pain.

    Topical NSAID (Diclofenac)

    • Diclofenac 1% gel for topical application.
    • Indicated for osteoarthritis pain.
    • Targeted for osteoarthritis in various joints.
    • Awareness of safety concerns and monitoring for systemic absorption.
    • Used to treat osteoarthritis

    Diclofenac Dosing

    • Dosage for different body parts (Upper extremity and lower extremity).
    • Maximum daily doses.

    Instructions for Use

    • Application instructions for diclofenac gel.
    • Avoiding contact with mucous membranes, open wounds, or exposed skin.
    • Using gloves to prevent skin contact during application.
    • Restrictions on use of the product

    Topical Diclofenac (Pennsaid)

    • Diclofenac topical solution (2%).
    • Applying diclofenac solution on the affected knee.
    • Frequency of administration (twice daily).

    Topical Diclofenac Safety Considerations

    • Topical diclofenac safety warnings.
    • Usage contraindications.
    • Potential warnings and precautions for topical diclofenac use.
    • Contraindications to the topical application

    Topical NSAID (Diclofenac)

    • Advantages: Safer than oral NSAIDs, Fewer gastrointestinal complications.
    • Efficacy: Similar to oral diclofenac.
    • Skin Reactions: Potential for local skin reactions (itching, rashes).
    • Monitoring: Drug interactions must be monitored.

    Intraarticular Glucocorticoid

    • Recommended for knee and hip osteoarthritis (may work on hands).
    • Limited frequency (every three months or 3-4 times annually maximum).
    • Quick-acting with benefit within 1-2 days.
    • Risk of placebo effect due to effusion aspiration.
    • Ultrasound guidance preferred.

    Intraarticular Glucocorticoid Dosing

    • Dose customized to joint size
    • Methylprednisolone 4–80 mg.
    • Triamcinolone 10–40 mg

    Acetaminophen

    • Conditionally recommended for treating osteoarthritis in the knee, hip, or hand.
    • Evidence supports modest benefit.
    • Dose: 325–1000 mg every 4–6 hours.
    • Maximum daily dose: 4 g.
    • Liver/alcohol interaction: Limit dose to 2 g daily if alcohol or liver issues.
    • Major advantage: Low risk of gastrointestinal or cardiovascular side effects.
    • Concern: Hepatotoxicity with long-term use exceeding 3 g daily.

    Duloxetine (Cymbalta®)

    • SSRI and norepinephrine reuptake inhibitor.
    • Modest effectiveness in treating knee osteoarthritis.
    • Potential treatment for chronic musculoskeletal pain, neuropathic pain, depression, and anxiety.

    Duloxetine Dosage

    • Initial dose: 30 mg daily for one week.
    • Maintenance dose: 60 mg daily.
    • Gradual dose titration (2–4 weeks).
    • Dosage restrictions: Contraindicated with CrCl less than 30 mL/min.

    Capsaicin

    • Derived from chili peppers.
    • Depletes substance P, leading to diminished pain sensation.
    • No action on blood vessels, so no redness.
    • Used for pain relief of knee osteoarthritis, rheumatoid arthritis, and other neuropathic conditions.

    Capsaicin Application

    • Onset: Relief may take 14 days or longer, possibly up to 4–6 weeks.
    • Frequency: Applied 3–4 times daily.
    • Glove usage.
    • Contact time.
    • Pre-treatment (often with lidocaine) for new users.
    • OTC availability.
    • Prescriptions may include a patch (Qutenza)

    Tramadol (Ultram®)

    • Synthetic opioid agonist, affecting norepinephrine and serotonin receptors.
    • Potential similar effect to ibuprofen for hip and knee osteoarthritis.
    • Use in combination with NSAIDs or APAP (acetaminophen).
    • Dosage: Immediate-release (IR) 25–50 mg every 6 hours, 300–400 mg maximum daily (in older adults).

    Tramadol (Ultram®) - Additional

    • Label includes opioid warnings about addiction, misuse, death, and respiratory depression.
    • Adverse effects: nausea, constipation, drowsiness.
    • Caution for people taking other medications that lower the seizure threshold (tricyclic antidepressants, first-generation antipsychotics).
    • Increased risk of serotonin syndrome with other serotonin-increasing medications (like duloxetine).

    Chondroitin

    • Mucopolysaccharide in mammalian cartilage.
    • Thought to enhance joint matrix formation and decrease breakdown of old cartilage.
    • Evidence for benefit in hand osteoarthritis.
    • Slow acting with improvements possibly observable after 3 months.
    • Generally safe but with minimal data.
    • Dosage: 800-2000 mg daily or divided doses.

    Glucosamine

    • Naturally occurring substance found in cartilage.
    • Component of proteoglycans in cartilage formation.
    • Recent guidelines discourage its use generally (more evidence is necessary).
    • Side effects: abdominal pain, heartburn, diarrhea.
    • Long term (≥ 2 months) benefit.
    • Dosage(generally 1500mg daily sulfate)

    Intraarticular Hyaluronic Acid

    • Component of synovial fluid, reducing viscosity in OA.
    • Obtained from rooster combs.
    • Recommended use: 3-5 times/week (10, 20 mg intra-articular).
    • Effectiveness: Demonstrates effectiveness in 5-13 weeks, lasting approximately 24 weeks, with side effects like pain or swelling.
    • Cautions: Guidelines recommend against use for hip and some guidelines advise caution for knee and first CMC joint.

    Surgery (Arthroplasty)

    • Arthroplasty (joint replacement procedure) is considered when osteoarthritis has progressed and is unresponsive to other treatments.
    • Indicators for surgery include severe osteoarthritis, progressively limited activities of daily living (ADLs), substantial joint damage, persistent pain despite therapy.
    • The procedure typically involvea replacement of the affected joint with a prosthetic.

    Knee Replacement

    • Surgical procedure to replace the damaged knee joint with a prosthetic to ease discomfort.

    Hip Replacement

    • Surgical procedure to replace the damaged hip joint with a prosthetic to eliminate or reduce persistent hip discomfort.

    Aspirin

    • Anti-inflammatory: Requires 3.6 grams daily to achieve a significant anti-inflammatory effect.
    • Analgesic: Offers mild to moderate pain relief.
    • Antipyretic: Reduces fever via vasodilation.
    • Platelet Inhibition: Irreversibly inhibits platelets for approximately 8 days for normal function again.

    Aspirin Side Effects

    • Gastrointestinal issues (ranging from mild discomfort to severe complications).
    • Decreased platelet aggregation elevates the risk of bleeding.
    • Central nervous system issues (tinnitus and vertigo).
    • Allergy to aspirin or intolerance.
    • Reye's Syndrome (in children).

    Non-acetylated Salicylates

    • Less potent anti-inflammatory effects than acetylsalicylic acid (ASA).
    • Fewer gastrointestinal problems compared to acetylsalicylic acid.
    • Exhibits lower platelet inhibition effects.
    • Potentially beneficial for asthma, but risks exist pertaining to renal dysfunction.
    • Various types include magnesium salicylate, salsalate, diflunisal, and choline magnesium salicylate.

    Opioids

    • Opioid use, even in combination with acetaminophen, should be initiated at a low dose and adjusted slowly.
    • Frequent adverse effects include nausea, vomiting, and constipation, along with drowsiness.
    • Respiratory depression/falls, and addiction are significant threats.

    Safety Information for NSAIDs

    • Gastrointestinal side effects (dyspepsia, heartburn, abdominal pain, nausea, and diarrhea) are potential risks with NSAID use.
    • GI symptoms may be alleviated by taking the medication with food, milk, or antacids (especially in enteric-coated formulations).
    • Ulceration and bleeding are major concerns, occurring in 1.5–4% of individuals treated with NSAIDs.

    Risk Factors for GI Events

    • Age greater than 60 years presents an elevated risk of complications.
    • Previous history of ulcers or bleeding is a significant risk factor.
    • Cardiovascular disease is a risk factor.
    • Use of corticosteroids, antiplatelet agents, or anticoagulants significantly elevates risk. NSAID dose.

    Gastrointestinal Risk and Treatment

    • Treatment/Prophylaxis should be considered against potential ulcers for patients.
    • Proton pump inhibitors (proton pump inhibitors) can be prescribed as a treatment.
    • Patients may benefit from prostaglandin analogs (misoprostol/diclofenac) in treating osteoarthritis.
    • COX-2 inhibitors (e.g., celecoxib) exhibit a lower GI risk.

    NSAIDs Versus COX-2 Inhibitors

    • No notable efficacy difference between NSAIDs and COX-2 inhibitors (e.g., celecoxib).
    • Adverse impacts on glomerular filtration (sodium retention) from COX-2 inhibitors (e.g., celecoxib).
    • COX-2 inhibitors are contraindicated in individuals allergic to sulfonamides.

    Cardiovascular Risk

    • Elevated risk of myocardial infarction, stroke, and other cardiovascular thrombotic events are observed.
    • Vasoconstriction and platelet aggregation are risk factors.
    • Patients with conditions like unstable angina, prior myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, ischemic stroke, and elevated blood pressure require heightened vigilance.

    Cardiovascular Risk (Continued)

    • Specific agents (diclofenac) show a slightly greater risk relative to other agents (naproxen).
    • Concurrent use of NSAIDs and aspirin can impact aspirin's effectiveness (cardioprotection).
    • Spacing NSAIDs and aspirin administrations.
    • Consider GI protection with proton pump inhibitors (PPIs).

    Renal Side Effects

    • Renal dysfunction is a possible side effect of prostaglandins inhibition.
    • Caution is required for use in patients exhibiting volume overload, reduced cardiac output, congestive heart failure (CHF), liver disorders with ascites, compromised renal function, or concomitant diuretic administration.
    • Clinicians should closely monitor patients for high blood pressure changes of more than 5mmHg, especially when using NSAIDs.

    Other Side Effects (Other SEs)

    • Potential neurological issues (cognitive impairment, drowsiness, dizziness, and behavioral changes).
    • Rare likelihood of hepatotoxicity and respiratory problems (such as exacerbations of asthma).
    • Dermatological symptoms (e.g., rashes, itching, bruises, or sweating) may appear in some individuals.

    Drug Interactions

    • Potentially adverse effects observed with combination usage with antihypertensives (such as ACE inhibitors, beta-blockers).
    • Risk of elevated bleeding.
    • Interactions with bisphosphonate medications increase the incidence of GI irritation.
    • The combined use of salicylates and NSAIDs reduces the effectiveness of NSAIDs.

    Sources

    • Various articles and guidelines from reputable sources, including the American College of Rheumatology, the Arthritis Foundation, and published research studies.

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    Description

    This quiz focuses on osteoarthritis, including its pathophysiology, clinical presentation, and risk factors. Students will analyze a case study involving a 60-year-old female patient, learn to create treatment plans, and explore patient education regarding this condition. Prepare to dive deep into both the theory and practical aspects of managing osteoarthritis.

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