Osteoarthritis Treatment PDF

OSTEOARTHRITIS Dr. Ellen Schellhase Department of Pharmacy Practice PHRM 825 PATIENT SCENARIOS JD is a 68 year old female with symptomatic joint pain for the past 3 weeks SK is a 49 year old male who is complaining of increasing hip pain at rest despite taking acetamino...

OSTEOARTHRITIS Dr. Ellen Schellhase Department of Pharmacy Practice PHRM 825 PATIENT SCENARIOS JD is a 68 year old female with symptomatic joint pain for the past 3 weeks SK is a 49 year old male who is complaining of increasing hip pain at rest despite taking acetaminophen LG is a 70 year old female who is complaining of difficulty ambulating despite using tramadol  PATHOPHYSIOLOGY degenerative changes that occur in cartilage and the associated bone characterized by increased destruction and subsequent proliferation of cartilage and bone http://www.umm.edu/patiented/articles/what_osteoarthritis_000035_1.htm INCIDENCE Observed more commonly in older patients Most common joint-related disease - almost 85% of pt > 75 years - severity of disease increases with age - more common in females JOINT INVOLVEMENT distal interphalangeal joint hips knees https://accesspharmacy.mhmedical.com/content.aspx?sectionid=267341739&bookid=3097&Resultclick=2 RISK FACTORS Increased age Female Obesity Repetitive stress Congenital defects Major joint trauma Muscle weakness Heredity  CLINICAL MANIFESTATIONS Joint pain AM stiffness Crepitus Inflammation Muscle atrophy Asymmetric involvement Buys LM, Elliott ME. Chapter 101. Osteoarthritis. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=7997482. Accessed April 16, 2013.  CLINICAL MANIFESTATIONS No systemic symptoms Instability of weight bearing joints Herberden’s nodes Bouchard’s nodes Buys LM, Elliott ME. Chapter 101. Osteoarthritis. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=7997482. Accessed April 16, 2013.  I have pain when I wake up My knee is tender or sore after overuse I feel pain in my knee even when I am not active Getting up from a chair, out of a car, or going up or down stairs is difficult I hear a crackling sound in my knee when I move I experience a grating feeling in my knee when I move The area around my knee is red and swollen I am unable to do or enjoy certain activities because of pain or stiffness in my knee I feel less coordinated due to pain or stiffness in my knee I have noticed the muscles in my leg are not as strong as they used to be http://supartzprofessional.com/docs/Supartz_OA_Self_Assesment_Form.pdf PATIENT SCENARIO JD is a 68 year old Caucasian female with symptomatic joint pain for the past 3 weeks. She is overweight. She suffers from peptic ulcer disease, hypertension, and diabetes.  She was a seamstress but is no longer employed. She does not have adequate health insurance coverage for prescriptions. JD complains that the joints in her hands are painful, particularly her right hand. The pain is worse after she does housework and uses the computer to contact her grandchildren. GOALS OF THERAPY Relief of pain and discomfort Maintain function of joint and strength TREATMENT OF OA Non-drug therapy  TREATMENT OF OA Non-drug therapy Drug therapy – based on hand, knee/hip – Topical therapy – Oral agents – Supplements – Injectables  Knee and Hip Treatment Treatment recommendations for knee and hip osteoarthritis. (CV, cardiovascular; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs.) Source: Osteoarthritis, Pharmacotherapy: A Pathophysiologic Approach, 10e Citation: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e; 2017 Available at: http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=133893029 Accessed: April 18, 2017 Copyright © 2017 McGraw-Hill Education. All rights reserved  Hand Treatment Treatment recommendations for hand osteoarthritis. (CV, cardiovascular; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs.) Source: Osteoarthritis, Pharmacotherapy: A Pathophysiologic Approach, 10e Citation: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e; 2017 Available at: http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=133893029 Accessed: April 18, 2017 Copyright © 2017 McGraw-Hill Education. All rights reserved Treatment of Osteoarthritis Non-Pharmacologic Therapy Psychological support Education Rest Physical activity / exercise Heat / Ice Physical Therapy Occupational Therapy Weight Loss http://www.uwo.ca/actage/pdf/Aging,%20Physical%20Activity%20and%20Arthritis%20Sept272010.pdf  TREATMENT OF OA Non-drug therapy Drug therapy – based on hand, knee/hip – Topical therapy – Oral agents – Supplements – Injectables Treatment of Osteoarthritis Topical Therapy Menthol Camphor Oil of Wintergreen (methyl salicylate) Topical Counterirritant Dose: apply multiple times per day Topical Therapy Capsaicin Cream ( Zostrix ) MOA: depletes substance P Dose: apply sparingly to affected joints 2 - 4 times daily Wait 2-4 weeks to evaluate results Adverse Effects: burning, stinging, and redness Topical Therapy Diclofenac Gel 1% - Voltaren Gel MOA: local inhibition of COX-2 enzymes Dose: Applied to joint QID Max 16g to any one joint daily Not recommended in combination with systemic NSAID Adverse Effects: pruritus, burning, pain and rash  DICLOFENAC GEL APPLICATION http://www.voltarengel.com/consumer/about_voltaren.aspx Topical Therapy Diclofenac Topical Solution % - Pennsaid For knee only Dose: – 40 drops (40mg) to each knee QID – Apply 10 drops at a time – 2 pumps (40mg) twice daily Local reaction most common adverse effect DICLOFENAC SOLUTION APPLICATION http://www.pennsaid.com/How-to-apply-PENNSAID.aspx Acetaminophen (Tylenol ) MOA: inhibits synthesis of prostaglandins Dose: Max: 3g – 4g per day Two – four week trial www.tylenol.com ACETAMINOPHEN ACETAMINOPHEN Patients at risk for hepatotoxicity – Heavy EtOH intake – Pre-existing liver disease Monitor ALT/AST annually if on routine doses NSAIDs No two patients respond the same If patient does not respond → switch to alternative NSAID NSAIDs MOA: Dosing: Analgesic v. anti-inflammatory Buys LM, Elliott ME. Chapter 101. Osteoarthritis. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=7997482. Accessed April 16, 2013. NSAID Therapy Analgesic vs. Anti-inflammatory dose – Naproxen 220 mg q 8-12 hours – Naproxen 440 mg q 8-12 hours – See table in chapter for agents & dosing – Most patients respond to analgesic dose 1-2 week trial for pain and 2-4 week trial if inflammation exists NSAID Therapy Adverse Effects: Greatest Risk for AE – GI upset – dose dependent – ulcers – age > 75 – bleeding – h/o GI bleed – renal dysfunction – h/o of PUD – Increase BP – anticoagulants – Increased risk of – antiplatelet stroke, MI, and – glucocorticoids death  NSAID Therapy Patients at greatest risk for nephrotoxicity – CHF – HTN – renal dysfunction – dehydration Patients at greatest risk for cardiovascular AE’s – CHF – CVD http://www.hpsm.org/documents/SCORE_for_NSAID_Risk_Tool.pdf MONITORING NSAIDs blood pressure signs of edema or weight gain SCr - every 3 months Hgb / Hct - every 6 - 12 months signs of dehydration COX-2 INHIBITORS COX-2 Inhibitors Celebrex® Dose: 100 - 200 mg orally daily or bid Lower incidence of GI bleeding Buys LM, Elliott ME. Chapter 101. Osteoarthritis. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=7997482. Accessed April 16, 2013. COX-2 INHIBITORS Potential risks associated with COX-2 Inhibitors: increased risk of cardiovascular disease same effects on renal function increase cost of therapy Combination Products NSAID + PPI – Vimovo® - naproxen + esomeprazole NSAID + misoprostol – Arthrotec® - diclofenac + misoprostol NSAID + H2 antagonist – Duexis® - ibuprofen + famotidine  Treatment of Osteoarthritis Pharmacologic Therapy Guidelines for NSAID use in OA Buys LM, Elliott ME. Chapter 101. Osteoarthritis. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=7997482. Accessed April 16, 2013. Opioid Analgesics Used PRN for breakthrough pain Dosing: – Start low and go slow – Use long acting (SR) and short acting (IR) Adverse Effects: – Nausea – Somnolence – Constipation – Dizziness TRAMADOL (Ultram®) MOA: affinity for µ receptor Dose: – 25-50 mg every 4-6 hours – Titrate to 200-300 mg per day Adverse Effects: – Nausea, vomiting, dizziness, constipation DULOXETINE (Cymbalta®) Adjunct medication Dose: 30mg/day x 1 week Max dose: 60mg daily Avoid with tramadol Adverse effects: gastrointestinal OTC Supplement Glucosamine/Chondroitin MOA: stimulates proteoglycan synthesis Dose: – 500 mg PO TID (glucosamine) – 400 mg PO TID (chondroitin) Slow onset (4 weeks) – 3 month trial is adequate Adverse Effects: gas, bloating, cramping, nausea Treatment of Osteoarthritis Intra-Articular Corticosteroid Injections only used for isolated joints no more than every 4-6 months actual injection can be quite painful peak pain relief in 7-10 days http://www.aafp.org/afp/2000/0801/p565.html www.hopkinsarthritis.org/arthritis-news Treatment of Osteoarthritis Hyaluronate Injections (Synvisc ) MOA: temporary increase in viscosity Dose: injected into joint weekly for 3 - 5 weeks Maximum benefit in 8-12 weeks Used for patients who do not tolerate other treatments or are not candidates for surgery Only local adverse effects (minor swelling) Treatment of Osteoarthritis Joint Replacement Surgery Relieves pain at rest Restores function to the joint Last 10-15 years Newer materials last longer http://health.rush.edu/HealthInformation/mens%20center/2/9494.aspx MONITORING PARAMETERS Pain (at rest) Degree of disability Joint stability and Weight function ADRs from medications Risk of fall Compliance with non- Range of motion drug measures X-rays QOL issues  FUTURE/ALTERNATIVE TREATMENTS Acupuncture Strategies/targets: cartilage, synovial membrane, subchondral bone DMOAD – disease modifying osteoarthritis drugs Stem cell therapy Ghouri A, Conaghan P. Updates on novel pharmacologic therapies for osteoarthritis. Ther Adv Musculoskelet Dis. 2019. doi: 10.1177/1759720X19864492  Knee and Hip Treatment Treatment recommendations for knee and hip osteoarthritis. (CV, cardiovascular; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs.) Source: Osteoarthritis, Pharmacotherapy: A Pathophysiologic Approach, 10e Citation: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e; 2017 Available at: http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=133893029 Accessed: April 18, 2017 Copyright © 2017 McGraw-Hill Education. All rights reserved  Hand Treatment Treatment recommendations for hand osteoarthritis. (CV, cardiovascular; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs.) Source: Osteoarthritis, Pharmacotherapy: A Pathophysiologic Approach, 10e Citation: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 10e; 2017 Available at: http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=133893029 Accessed: April 18, 2017 Copyright © 2017 McGraw-Hill Education. All rights reserved US Pharm. 2023;48(3):17-21. PATIENT CASE CD is a 78 yo woman with osetoarthritis of the hips, knees, and hands. She comes to the pharmacy looking for “something stronger than Tylenol” to treat her pain. When you ask her to elaborate, she complains that she has tried Tylenol but it “does not work” for her. PATIENT CASE SK is a 71 yo man with a h/o PUD and current osteoarthritis. Until recently, SK has been able to manage his pain adequately with Tylenol 1000 mg QID. His pain is getting worse and he visits the physician seeking something “stronger.” SK’s physician decides to initiate therapy with Mobic 7.5 mg daily. Given SK’s history, what else may be done to reduce his risk of GI complications?