Osteoarthritis

Pathophysiology of Osteoarthritis is a ____ cycle

"Vicious cycle"

What are the 3 Acetaminophen strength that are available as over-the-counter (OTC) ?

- 300 mg -- Regular strength - 500 mg -- Extra strength - 650 mg -- Osteoarthritis

Determine goals of therapy

- Individualize for each patient - Resolution of current symptoms - Prevention or reduction in disease progression - Maintain or improve functional ability - Implement both nonpharmacologic intervention - Pharmacologic interventions

Osteoarthritis is also known as the "_____" or characterized by _____

1. "Wear and tear" arthritis 2. Degenerative joint disease (DJD) - erosion of joint cartilage; bone to bone causes the pain

Case 1: What is the most appropriate oral treatment option for a 60 year old female recently diagnosed with mild OA of both knees? She has not tried any medications for this condition yet. Her past medical history is significant for upper GI bleed (9/2020) Provide a medication name and dosing regimen.

1. Acetaminophen 2. Topical NSAIDs 3. Do not recommend any oral NSAIDs because of the risk of GI. Even though Celecoxib is a COX2 inhibitor, which has lower GI risk, it is still a risk

What are some consideration when recommending exercises for patients with arthritis

1. Aerobic and/or resistance / Aquatic exercises 2. If patient is unable to do aerobic/resistance or aquatic exercises: Assistive devices, patellar taping, thermotherapy, tai chi (only studied for OA of knee)

As previously discussed, long term use of oral NSAIDs can have Gastrointestinal (GI) side effects. What are possible risk factors that can lead to GI side effects

1. Age ≥65 years old 2. History of GI bleed or ulcer 3. Concomitant use of steroids (e.g. prednisone) 4. Concomitant anticoagulants (e.g. warfarin)

List surgical procedures for osteoarthritis

1. Arthroscopic lavage 2. Debridement, irrigation 3. Knee or hip replacements

Describe the Pathophysiology of Osteoarthritis

1. Breakdown of joints 2. Loss of hyaline cartilage 3. Remodeling of adjacent bone as an osteophyte 4. Repair process of synovial joints 5. Overwhelming insult prevents joint repair Causing Progressive breakdown of the joints, leading to bone on bone = viceous cycle (a negative series of events that build on and reinforce each other.)

As already discussed, Topical NSAIDs is one of the 3 first-line treatment options to treat all severity for localized Osteoarthritis of the Hands or Knees. What are the three available Topical NSAIDs for osteoarthritis?

1. Diclofenac gel (Voltaren®) 2. Diclofenac patch (Flector®) 3. Diclofenac Solution (Pennsaid®)

Identify a nonpharmacologic treatment for osteoarthritis

1. Exercise 2. Weight loss that is tailored to the individual patient 3. Acupuncture (insertion of very thin needles through your skin) 4. Manual Therapy (not very recommended cause it worsens osteoarthritis, however, if patients say it works then advise them to continue) 5. Total Joint Replacement

List long term adverse effects of oral NSAIDs

1. Gastrointestinal (GI) -ulcer, bleeding 2. Renal dysfunction 3. Anti-platelet effects 4. Cardiovascular risk/BP

Identify risk factors for developing osteoarthritis

1. Genetics 2. Older age (above 50) 3. Obesity 4. Female gender 5. Over usage 6. Injury 7. Reduced muscle strength

The three commonly affected locations by osteoarthritis are

1. Hand 2. Hip 3. Knee

What are the common over-the-counter Oral NSAIDs (w/ dosing) used for osteoarthritis?

1. Ibuprofen 200-400mg PO Q6-8 hrs PRN pain 2. Naproxen 220mg PO Q8-12 hrs PRN pain

What are the common prescription (Rx) Oral NSAIDs (w/ dosing) used for osteoarthritis?

1. Ibuprofen 200-800mg PO Q6-8 hrs PRN pain 2. Naproxen 250-500mg PO Q12 hrs PRN pain 3. Celecoxib 200mg PO once daily

Identify signs and symptoms of osteoarthritis

1. Morning stiffness that improves within 30 minutes of activity 2. Persistent joint pain that worsens with the use 3. Crepitus (cracking or popping sounds in a joint) 4. Decreased range of motion 5. Bony swelling/enlargements (seen on X-ray) 6. Radiologic evidence with the absence of inflammatory markers

Tramadol is a _____ agonist and have _____ properties

1. Partial μ-opioid agonist 2. Serotonin-norepinephrine reuptake inhibitor

Among all the pharmacological treatment options for osteoarthritis, The First-line therapies option for osteoarthritis are

1. Topical NSAIDs 2. Acetaminophen 3. Oral NSAIDs

Osteoarthritis is the most common type of arthritis that affects the _____ and other ____ joints

1. weight-bearing 2. moveable joints

The maximum OTC dose Ibuprofen for osteoarthritis patients are

1200mg/day

The maximum Rx Naproxen dose for osteoarthritis patients are

1500mg/day

What is the max dose recommended for acetaminophen for an adult with chronic alcohol (≥ 3 drinks/d)?

2 g/day

What is the max dose recommended for acetaminophen for an adult with concomitant warfarin?

2 g/day

What is the max dose recommended for acetaminophen for an adult with poor nutrition intake?

2 g/day

What is the max dose recommended for acetaminophen for an adult with pre-existing liver disease?

2 g/day

What is the dosing of Diclofenac gel (Voltaren®)

2-4g applied 4x daily (max: 32g/day)

The maximum Rx Ibuprofen dose for osteoarthritis patients are

3200mg/day

What is the typical dosing range for Acetaminophen?

325mg - 1000mg PO Q 4-6 hrs

What is the max dose for acetaminophen for an healthy adult?

4 g/day

Which dosing strength of Acetaminophen is marketed for Arthritis (osteoarthritis)

650 mg strength

The maximum OTC dose Naproxen for osteoarthritis patients are

660mg/day

The current data most strongly supports the use of this opioid medication in patients with Osteoarthritis

oxycodone

Do not recommend Tramadol to osteoarthritis patients with history of

seizures

Do not recommend Glucosamine and chondroitin in patients with ____ allergy

shellfish allergy

This drug is a Adjunctive therapy for osteoarthritis of the knee. It is a Serotonin-norepinephrine reuptake inhibitor indicated for major depression, neuropathic pain, fibromyalgia, and generalized anxiety disorder

Duloxetine (Cymbalta)

What would you consider when selecting nonselective and selective oral NSAIDs

GI & CV risks when selecting agent

_____ and _____ are OTC supplements that can be an alternative option for osteoarthritis in patients with contraindications to or intolerance of preferred therapy

Glucosamine and Chondroitin

Topical Non-steroidal anti-inflammatory drugs (NSAIDs) is a pharmacological treatment option for patients with osteoarthritis. Topical NSAIDs is recommended for

Hands or Knees

Tramadol is a pharmacological treatment option for patients with osteoarthritis. Tramadol is recommended for

Hands, Hips, and Knees

Acetaminophen is a pharmacological treatment option for patients with osteoarthritis. Acetaminophen is recommended for

Hands, Hips, or Knees

Oral NSAIDs are a pharmacological treatment option for patients with osteoarthritis. Oral NSAIDs is recommended for

Hands, Hips, or Knees

Case #2 What is the most appropriate treatment option for a 48-year-old female who presents with OA of the left knee and right hip with inflammation? And If Her primary care provider approaches you for a recommendation. Which of the following is best to recommend for this patient? A) Ibuprofen B) Morphine C) Tramadol D) Duloxetine

Ibuprofen

This therapy option is only recommended for osteoarthritis if patients fail first-line, second-line, and third-line therapy.

Injectable Agents for osteoarthritis

This Injectable Agents for osteoarthritis is reserved for moderate-to-severe OA of knee

Intra-articular hyaluronic acid

This Injectable Agents for osteoarthritis is a second-third line option (typically used at a stage prior to consideration of surgery). It is a Short-term, palliative relief of painful symptoms

Intra-articular steroids: triamcinolone, methylprednisolone

As already discussed, Oral NSAIDs are one of the 3 first-line treatment options to treat moderate-to-severe Osteoarthritis (pain) of the Hands, Hips, or Knees. What are the therapeutic properties/effects of NSAIDs?

It is 1. Analgesic (reduced pain) 2. Anti-pyretic (reduced fever) 3. Anti-inflammatory

As already discussed, Acetaminophen is one of the 3 first-line treatment options to treat mild-to-moderate Osteoarthritis of the Hands, Hips, or Knees. What are the therapeutic properties/effects of Acetaminophen?

It is 1. Analgesic = reduced pain 2. Antipyretic effects = reduced fever 3. No anti-inflammatory

Signs/symptoms of osteoarthritis includes

Joint pain & stiffness

NSAIDs are divided into nonselective and selective NSAIDs based on adverse effects. Is there a difference in efficacy?

NO

This drug is a third-line option for moderate-to-severe osteoarthritis in patients that have contraindications to other oral agents or respond insufficiently to acetaminophen and NSAID therapy

Opioids

This First-line therapy option is used to treat moderate-to-severe Osteoarthritis of the Hands, Hips, or Knees

Oral NSAIDs

What Osteoarthritis patients do you want to avoid giving Acetaminophen to

Osteoarthritis Patients with liver failure because acetaminophen is clear/metabolized through the liver

Is osteoarthritis a Mono- or polyarticular pattern and it is symmetrical or asymmetrical? - mono or polyarthritis means effect 1 or more joints at the same time

Osteoarthritis can be Mono- or polyarticular pattern and it is asymmetrical

List some Adverse Effects oral NSAIDs

Peripheral edema Elevated blood pressure Weight gain Renal insufficiency

What can you recommend for osteoarthritis patients whom you want to recommend oral NSAIDs for treatment but have a risk for GI side effects?

Since GI side effects are lower in COX2 inhibitors, You can recommend Celecoxib, which is the only COX2 inhibitors - COX2 inhibitors with proton pump inhibitor (PPI) or misoprostol

This therapy option for osteoarthritis is recommended only for severe pain and severe functional limitation after failing core treatments. It requires the history of mechanic locking or radiographic evidence of loose bodies

Surgery option for osteoarthritis

This Topical Agent must be used for more than 1 month for effectiveness. It can be considered an adjunctive therapy for osteoarthritis of the hand or knee. It may also lead to redness & burning sensation which is why it has a high discontinuation rate.

Topical Capsaicin (Capzasin-HP)

These Topical Agent Can be considered adjunctive or monotherapy for osteoarthritis of the hand or knee.

Topical NSAIDs

This First-line therapy option is used to treat all severity for localized Osteoarthritis of the Hands or Knees

Topical NSAIDs

This Topical Agent may be a modest improvement in pain of superficial joints and can be considered an adjunctive therapy for osteoarthritis of the hand.

Topical Salicylate (Aspercreme)

This drug is a second-line OTC option for moderate-to-severe osteoarthritis. It is recommended as an alternative (either monotherapy or combination) for patients that have contraindications to other oral agents or respond insufficiently to acetaminophen and NSAID therapy

Tramadol

What is the Brand name for Acetaminophen?

Tylenol

What is the brand name for Diclofenac gel

Voltaren®

What should you do if an osteoarthritis patient have a partial response to an agent you recommend

add adjunctive therapy or switch to a different therapy

What should you do If a patient does not respond adequately to one oral NSAIDs

adding adjunctive therapy or changing to different NSAID

You should considered avoiding oral NSAIDs with ____ therapy

anticoagulant therapy

Why would you prefer Topical NSAIDs to oral NSAIDs

for patients at risk of gastrointestinal (GI), cardiovascular (CV), or nephrotoxic adverse events

Glucosamine and chondroitin are not recommended for osteoarthritis of the ____ or ____ due to lack of clinical efficacy

knee or hip

This The First-line therapy option is used to treat mild-to-moderate Osteoarthritis of the Hands, Hips, or Knees

Acetaminophen

As previously discussed, long term use of oral NSAIDs can have Anti-platelet effects. Anti-platelet effects are highest with this drug?

Aspirin

Why are higher dose Oral NSAIDs prescription only

Because Higher doses have anti-inflammatory properties

As previously discussed, long term use of oral NSAIDs can have Cardiovascular risk and increased BP. The risk of cardiovascular disease is higher in ____ inhibitors

COX2 inhibitors

Which Topical NSAIDs is FDA approved

Diclofenac gel

Which Topical NSAIDs is not FDA approved but yet still available

Diclofenac patch (Flector®)