Osteoarthritis Lecture PDF

Osteoarthritis Definition ❑Osteo= bone, arthr=(arthran) joint, itis= inflammation  ❑Osteoarthritis is a degenerative disorder of the articular cartilage associated with hypertrophic changes in the bone ❑ “ Wear and Tear” : osteoarthritis is the most common form of a...

Osteoarthritis Definition ❑Osteo= bone, arthr=(arthran) joint, itis= inflammation  ❑Osteoarthritis is a degenerative disorder of the articular cartilage associated with hypertrophic changes in the bone ❑ “ Wear and Tear” : osteoarthritis is the most common form of arthritis and is strongly related to age. Pathogenesis ❑ Progressive loss of joint cartilage, subchondral damage, joint space narrowing, and changes in underlying bone and soft tissue may culminate in deformed, painful joints. Classification  Primary Secondary predominant form occurring developmental disorders or in the absence of a known inflammatory, precipitating event metabolic, or endocrine results from congenital or diseases Risk factors ❑ increased age ❑ female sex ❑ genetic predisposition ❑ Heavy physical activity ❑ Obesity increases load-bearing stress on hip and knee joints. Clinical Presentation ❑ The most common symptom of osteoarthritis is joint pain ❑ The pain tends to worsen with activity, especially following a period of rest; called “the gelling phenomenon” ❑ Osteoarthritis can cause morning stiffness, but it usually lasts for less than 30 minutes, unlike rheumatoid arthritis, which causes stiffness for 45 minutes or more ❑ Patients may report joint locking or joint instability ❑ These symptoms result in loss of function, with patients limiting their activities of daily living because of pain and stiffness Clinical Presentation ❑ The joints most commonly affected are the hands, knees, hips, and spine, but almost any joint can be involved ❑ Osteoarthritis is often asymmetric ❑ A patient may have severe, debilitating osteoarthritis of one knee with almost normal function of the opposite leg ❑Markers of inflammation, such as erythrocyte sedimentation rate and C-reactive protein level, are typically normal TREATMENT OF OSTEOARTHRITI  S Nonpharmacologic Management of OA ❑ Nonpharmacologic modalities are a primary strategy for OA treatment as pharmacologic management has significant adverse effects and modest efficacy in the control of OA pain and disability ❑ Education, exercise, weight loss, and cognitive behavioral intervention are integral components. ❑ Low-impact exercise is advisable for most patients, especially with knee or hip OA ❑ Referral to a physical or occupational therapist may be helpful ❑ Knee braces may delay the progression of knee OA  Pharmacologic Management of Osteoarthritis NSAIDs ❑ NSAIDs are the first-line therapy, regardless of affected joint location. ❑NSAIDs reduce pain and improve functioning in patients with OA. ❑ route of administration: oral or topical ❑ Topical NSAID administration minimizes systemic exposure while providing pain relief comparable to oral NSAIDs (Recommended in Knee OA). ❑ Deeper joints, especially the hip, should not be treated with topical NSAIDs owing to insufficient drug penetration. Pharmacologic Management of Osteoarthritis NSAIDs ❑ Topical diclofenac is marketed in a variety of preparations (ie, solution, gel, topical patch). ❑ Adverse effects of systemic NSAIDs: GI, renal, hepatic, cardiovascular, CNS and hypertensive effects ❑ COX-2 inhibitors are preferred for patients at high risk for GI complications. Pharmacologic Management of Osteoarthritis Acetaminophen ❑ Acetaminophen an inexpensive analgesic appropriate for short term/episodic use in those who cannot tolerate or have contraindications to NSAIDs. Pharmacologic Management of Osteoarthritis Duloxetine ❑ Duloxetine, a SNRI, is a centrally acting adjunctive option for patients achieving suboptimal response to oral NSAIDs. ❑ can be used as monotherapy or in combination with other agents. ❑may be preferred as an adjunct in patients experiencing concurrent neuropathic and musculoskeletal pain. ❑ Adverse effects: nausea, dry mouth, somnolence, constipation, decreased appetite, and hyperhidrosis Pharmacologic Management of Osteoarthritis Tramadol ❑ Tramadol is an oral, centrally acting synthetic opioid analgesic that also weakly inhibits serotonin and norepinephrine reuptake. ❑ only recommended in patients who have failed or have contraindications to other oral options. ❑ should be recommended over other opioid agents if an opioid is being considered. Pharmacologic Management of Osteoarthritis Tramadol ❑ Adverse effects: Dizziness, Vertigo Nausea, Vomiting Constipation, Lethargy Seizures (rare, dose-related and increase with concomitant use of antidepressants) Pharmacologic Management of Osteoarthritis Other Opioid Analgesics ❑ Opioid analgesics other than tramadol are reserved for patients experiencing severe pain for which alternative options are inadequate or contraindicated (eg, renal failure, heart failure, anti-coagulation). ❑ Opioids greatly increase the risk for addiction and other serious adverse effects that limit their use in most patients. Pharmacologic Management of Osteoarthritis Intra-Articular Therapy ❑ used after failure of first-line oral or topical NSAID therapy. ❑ Two therapies, glucocorticoids and hyaluronic acid, are approved for IA injection. ❑ Glucocorticoids are strongly recommended over hyaluronic acid. ❑ Both treatments are used to improve symptoms but do not reverse disease progression.  Pharmacologic Management of Osteoarthritis Intra-Articular Therapy ❑ Glucocorticoids with reduced solubility, such as methylprednisolone and triamcinolone, are usually preferred. ❑ A single joint should generally not be treated more than every 3 months to reduce the risk of glucocorticoid-induced cartilage and joint damage. ❑ Patients with OA demonstrate an absolute and functional decline in hyaluronic acid; thus, exogenous administration is referred to as viscosupplementation. Pharmacologic Management of  Osteoarthritis Over-the-Counter Agents Glucosamine and Chondroitin ❑ Glucosamine is believed to function as a “chondroprotective” agent, stimulating the cartilage matrix and protecting against oxidative chemical damage. ❑ Guidelines do not support the use of glucosamine due to inconsistent efficacy and large placebo effects in most trials. Despite this, glucosamine is one of the most commonly used dietary supplements. ❑ Chondroitin is thought to inhibit degradative enzymes and serve as a substrate for proteoglycan production. Pharmacologic Management of Osteoarthritis Other Topical Agents ❑Capsaicin relieves pain by depleting substance P from spinal sensory neurons, thereby decreasing pain transmission. ❑ Capsaicin is not effective for acute pain; it may take up to 2 weeks of daily administration to relieve pain. The lower concentration (0.025%) is better tolerated, but most patients experience a localized burning sensation Pharmacologic Management of Osteoarthritis Other Topical Agents ❑ Limited data support use of salicylate-containing rubefacients (eg, methyl salicylate, trolamine salicylate) or other counterirritants (eg, menthol, camphor, methyl nicotinate) in OA. Pharmacologic Management of Osteoarthritis Surgery ❑ Surgery generally is reserved for patients who fail medical therapy and have progressive limitations in activities of daily living. ❑ In joint replacement surgery (arthroplasty), the damaged joint surfaces are replaced with metal or plastic prostheses.  Summary 1- Def 2- Physiology and pathophysiology - Synovial cartilage - Chondrocyte function - Chondrocyte faiuler - Bone hypertrophy 3- Causes (1ry, 2ry) & Risk factors 4- Clinical presentation 5- Management: a) Non pharmacological b) Pharmacological - Oral (Acetaminophen, NSAIDs, Centrally) - Intraarticular (GC, hyaluronic acid) - OTC (Glucosamine and Chondroitin) - Other topical (Capsaicin , counter irritant) c) Surgery