DERM IE2 MATERIAL: OA

Osteoarthritis (OA)

risk factors

• obesity = most preventable risk factor

  • linked to knee and hip OA

  • lose 5 kg (11lbs) → reduce risk

• age

  • > 50 years old

• gender

  • common in women

• occupation

  • prolonged standing, anything joint movement related

• sports

• joint injury or surgery

• genetics

effects of OA

• commonly affected body parts

• sx

• commonly affected body parts

  • hand, hip, knee

• sx

  • pain

  • stiffness

  • crackling sound

  • extra bone growth

  • tenderness

clinical presentation of OA

• progressive or not?

• diagnosis

• progressive disease

• hx, PE, radiographic findings, labs

  • scans, no + on inflammatory markers

primary OA vs secondary OA

• primary = idiopathic (cause unknown)

• secondary = underlying cause

features and sx of OA

• gradual onset

• morning stiffness < 30 mins

• less inflammation

• pain relieved by rest

• limited ROM

• crepitus

• bone growth/tenderness

  • Herberdens

  • Bouchards

• ESR (erythrocyte sedimentation rate) = normal

• RF (rheumatoid factor) = negative

Herberden’s nodes vs Bouchard’s nodes

• herberden’s

  • bony enlargement of joint closest to fingertip (DIP)

• bouchard’s

  • bony enlargement of middle joint of fingers (PIP)

OA vs RA

• OA

  • degenerative (wear and tear)

  • less inflammation

  • normal ESR/CRP, negative RF

• RA

  • autoimmune

  • inflammation

  • elevates ESR/CRP, postive RF

prognosis of OA

• variable → depends on joints involved

• weight-bearing joint or spine involvement

• secondary OA → prog depend on underlying cause

T or F: meds for OA are for managing symptoms only

T: does not stop progression of OA

dietary recommendations

• best foods

• food to avoid

• best foods

  • broccoli, green tea, fruits, fish, olive/grapeseed/avocado oil, low-fat dairy products

• food to avoid

  • sugars, alcohol, saturated/trans fats, veggie/sunflower oil, carbs

non-pharmacologic recommendations for OA

• all

• knee, hip

• hand

• knee

• All (hand, hip, knee)

  • self efficacy and management

  • exercise

• knee, hip

  • weight loss

  • tai chi

  • cane

• hand

  • 1st carpmetacarpal orthosis

• knee

  • tibiofemoral brace

Pharmacological Recommendations: strongly recommned

• hand

• hip

• knee

• hand

  • oral NSAIDs

• hip

  • oral NSAIDs

  • IA steroids

• knee

  • Oral NSAIDs

  • topical NSAIDs

  • IA steroids

Pharmacological Recommendations: conditionally recommned

• hand

• hip

• knee

• hand

  • topical NSAIDs

  • IA steroids

  • APAP

  • tramadol

  • duloxetine

• hip

  • APAP

  • tramadol

  • duloxetine

• knee

  • APAP

    • tramadol

    • duloxetine

    • topical capsaicin

1st line treatment for all?

Oral NSAIDs

• short to moderate acting preferred (DOA: < 6hrs)

• avoid for pts w/ asthma who are aspirin intolerant

classes of NSAIDs: Nonsalicylates (Nonselective)

• Indomethacin

• Piroxicam

• Ibuprofen

• Naproxen

• Diclofenac

classes of NSAIDs: Nonsalicylates (partially selective)

• Etodolac

• Nabumetone

• Meloxicam

• Diclofenac

classes of NSAIDs: Nonsalicylates (selective COX-2 inhibitors)

• Celecoxib

classes of NSAIDs: Salicylates

• Acetylated (ASA)

• nonacetylated (Salsalate, Trisalicylate)

Celecoxib

• brand

• comments

• Celebrex

• not for pts w/ sulfa allergy

ibuprofen

• brand

• dosing

any

• brand

  • Motrin, Advil

• dosing

  • OTC max: 1200 mg

  • Max Rx dose: 3200 mg

Meloxicam

• brand

• dosing

• comments

• brand

  • Mobic

• dosing

  • 7.5 - 15 mg

• comments

  • slow onset

  • long duration

Naproxen

• brand

• dosing

• brand

  • Naprosyn

• dosing

  • OTC max: 660 mg (naproxen sodium)

  • Rx max for OA: up to 1500 mg for 6 months

Sulindac

• brand

Clinoril

NSAIDs

• ADRs

• BBW

• ADRs

  • nausea, dyspepsia, abdominal pain, flatuence, diarrhea

  • gi bleeding

  • CV events

  • HTN

  • drug-induced hepatitis

  • CNS effects: rash, drowsy, etc

• BBW

  • increased risk w/ CV disease

  • CI in CABG surgery

which has lower risk of ulcer complications? selective or nonselective

selective NSAIDs lower risk than nonselective NSAIDs (naproxen, ibuprofen)

which has lower risk of ulcer-related complications and symptomatic ulcers?

partially selective NSAIDs (meloxicam, etodolac)

which are associated with an increased risk of CV ADRs compared w/ placebo?

Celecoxib and nonselective NSAIDs (ibuprofen, diclofenac)

which is favored for pts with high CV risk?

naproxen

which is favored in pts with high GI risk?

Celecoxib

combo meds

• ibuprofen/famotidine

  • avoid if CrCl < 50 ml/min

• naproxen/esomeprazole

  • avoid if CrCl < 30 ml/min

• arthotec (diclofenac/misopristol)

• do not use other NSAIDs or ASA

oral NSAIDs DDIs

• lithium

• warfarin, NOACs, antiplatelets

• methotrexate

• ACEI

• BB

• diuretics

• celebrex

which reduces celebrex levels

• CYP2C9 inducers

  • rifampin

  • CBZ

  • phenytoin

which increases celebrex levels?

• CYP2C9 inhibitors

  • fluconazole

what does celebrex increase levels of due to CYP2D6 inhibition

antidepressant concentration

which NSAIDs block aspirin’s cardioprotective effect?

ibuprofen or COX 2 selective

topical NSAIDs

• 1st line for knee OA

• 2nd line for hand OA

• diclofenac = most effective

• fewer ADRs

IA glucocorticoids

• alternative 1st line for knee and hip OA

• given concomitant oral analgesics

• no more than q3 months → risk for systemic SEs

IA glucocorticoid

• drugs

• relief

• local ADRs

• systemic ADRs

• drugs

  • triamcinolone (kenalog)

  • methylprednisolone (Depo-Medrol)

• relief

  • relief seen 24 - 72 hrs

• local ADRs

  • infection, osteonecrosis, tendon rupture, skin atrophy

• systemic ADRs

  • edema, elevated BP, dyspepsia

  • hyperglycemia

T or F: systemic CS are recommended in OA

False

Zilretta

• triamcinolone acetonide ER injectable suspension

• 1st and only FDA approved ER IA therapy for OA knee pain

• 1 time only

APAP

• 2nd line treatment for hand, knee, hip OA

• lower risk of GI and CV events

• hepatotoxicity

  • most common risk factor for liver failure = alcohol

  • isoniazid

• high dose interact w/ warfarin

• APAP + NSAID = not recommended → increased risk for renal failure

Tramadol (Ultram)

• CIV

• 2nd line for hand, knee, hip OA

• not fda approved

• added to NSAIDs

• ADRs

  • seizures

• dosing

  • starting: 25 - 100 mg/day

  • IR: 25 mg

  • ER: 100 mg

  • max: 400 mg; over 75 years old: 300 mg

• w/ or w/o food

• renally dosed < 30 ml/min

• formulated as Ultracet

duloxetine (Cymbalta)

• adjunct to hip, knee, hand OA

• for muscoskeletal pain, neuropathic pain, MDD, GAD, fibromyalgia

• ADRs

  • n/v, constipation

  • fatigue, dizziness

  • SJS, liver failure

  • BBW: risk of suicide

• risk for serotonin syndrome when used with serotonergic meds

• 30 - 60 mg/day

• avoid in CrCl < 30 ml/min

topical Capscaicin

• alternative 2nd line for knee OA

• erythema, site pain

• takes up to 2 weeks to see effect

• 3-4x/day

IA Hyaluronic Acid

• not recommended

• Synvisc-One, Monovisc, Gel-One = 1 injection only

• relief up to 6 months

• very expensive

opioid analgesics

• 2nd line for knee and hip OA

• for short term pain control

• 1 agent at a time, low dose, monitor

• opioid misuse/abuse/addiction

Glucosamine and Chondroitin

• limited FDA review/regulation/evidence

• placebo effect

• sometimes formulated w/ MSM

• not recommended

• long term use safe

• d/c if no benefit after 3 months

• DDI w/ warfarin

tumeric

• thins blood

• caution on anticoagulants and warfarin, surgery

SAM-e

avoid w/ MAOI, antidepressant

ASU (avocado)

• increase bleeeding risk

• caution in anticoag, antiplatelets, NSAIDs

arthroplasty

total joint replacement of knee/hip