Osteoarthritis Presentation

moved improvewi Jointstiffnessthat pain Wgsnwigdivity 2 Asymnetrailjoint y OSTEOARTHRITIS Pharm 840 Spring 2025 February 25th, 2025 Christina Voskanian, PharmD OSTEOARTHRITIS: BACKGROUND swab • Osteoarthritis (OA) is defined as a degenerative joint disease • Osteoarthritis typically presents as joint pain or stiffness, especially after resting or not moving for a while I • Characterized by the gradual breakdown of cartilage • Affects over 32.5 million US adults • 528 million people worldwide have osteoarthritis in 2019 • 113% increase since 1990 OSTEOARTHRITIS: BACKGROUND • Common affected joints (common in weight bearing joints) • Hands • Knees • Neck • Hip • Lower back • Knee is most affected joint, hip and hand follow in prevalence • Increasing rates in obesity and injury may contribute to increase in osteoarthritis prevalence • Osteoarthritis is not a consequence of aging CHECKPOINT What is the most common joint affected by osteoarthritis? A. B. C. D. Hip Elbow Knee Finger CHECKPOINT Which part of the joint is commonly affected by osteoarthritis? A. B. C. D. Cartlidge Tendon Exterior muscle Ligaments CHECKPOINT Which of the following symptoms is the most common characteristic of osteoarthritis? A. B. C. D. Joint stiffness that improves with rest Joint stiffness that improves with movement Fever Weight loss CHECKPOINT Which demographic is at higher risk of developing osteoarthritis? A. B. C. D. Children Young adults Elderly women Middle-aged men QA RISK FACTORS ido MODIFIABLE • Obesity • Diet • Joint injury or overuse • Traumatic Injury • Repetitive mechanical stress • Physical activity/Occupation • Muscle strength QA RISK FACTORS NON-MODIFIABLE • Age • Risk increases with age • Sex • < 50 y/o: male > female • > 50 y/o: female > male • Genetics • Osteoarthritis in another body location • More likely to develop OA in multiple locations • Race • Some Asian populations have lower risk ETIOLOGY Primary OA • No known cause Secondary OA • Known cause • Inflammation did• Congenital factors • Trauma (injury) • Metabolic Disorders (T2DM, Obesity, Gout, RA) CLINICAL PRESENTATION • Signs and Symptoms • Pain • Described as deep, aching pain • Often in weight bearing joints • Pain is worse after activity • Stiffness • Improves with gradual movement, usually <30 min in the morning • Often characterized with stiffness once you “warm up” CLINICAL PRESENTATION Presentation Osteoarthritis Rheumatoid Arthritis Primary Joints Affected -Distal interphalangeal -Carpometacarpal -Metacarpophalangeal -Proximal interphalangeal Joint characteristics Hard/bony Soft, Warm, and Tender Stiffness Experience morning stiffness for less than 30 minutes upon waking -Morning pain and stiffness for more than 30 minutes -Worse after rest CHECKPOINT me arthritis w symmetric poly involumat Tastgic What presentation is often associated with osteoarthritis? A. B. C. D. cradlingpopping Erythema around joint Crepitus with movement Fluid accumulation within joint Muscle spasm around joint y CHECKPOINT How is osteoarthritis commonly diagnosed? A. CT Scan B. X-Ray C. Pain Scale D. MRI TREATMENT ALGORITHM First Line Patient Education Pharmacotherapy Scheduled Acetaminophen If APAP is Contraindicated or Additional Therapy Needed Capsaicin or topical NSAIDs Oral NSAIDs Tramadol Intra-articular corticosteroids Last Line Prescription Opioids TREATMENT: NON-PHARMACOLOGICAL a Increasing physical activity 2 Physical therapy with muscle strengthening exercises 3 Weight loss U Supportive devices 5 Surgery (typically joint replacement, if other treatment options have not been effective) TREATMENT: NON-PHARMACOLOGICAL • Hand • CMC (carpometacarpal) joint support • Exercise TREATMENT: NON-PHARMACOLOGICAL • Knee • • • • Exercise Weight loss Support (cane) TF (tibiofemoral) knee brace • Hip • Exercise • Weight loss • Support (cane) massogeyerapy TREATMENT: NOT ADVISEDmy CHECKPOINT Regorexersice Me weightless What is the best choice for non-pharmacological management of osteoarthritis? A. Cross fit B. Weight loss C. Kickboxing D. Smoking cessation PHARMACOLOGICAL TREATMENT PHARMACOLOGICAL TREATMENT Topical Therapy Capsaicin Topical NSAIDs Oral Therapy NSAIDs Acetaminophen (Tylenol) Tramadol Glucosamine and chondroitin Duloxetine Intra-articular Injections Corticosteroids Hyaluronic acid TOPICAL CAPSACIN found compound Cherifppers • Pharmacologic Category: Analgesic, Transient Receptor Potential Vanilloid 1 (TRPV1) Agonist • Derived from a chili pepper • Available in multiple forms (OTC, Rx) • Cream, gel, lotion, patch, liquid • Strength varies: • 0.0225%, 0.025%, 0.03%, 0.0375%, 0.05%, 8% (Qutenza Rx only) boy TOPICAL CAPSACIN • Administration/Dose: • Cream: avoid contact with eyes, wounds, damaged or irritated skin, or mucous membranes • Gently rub into painful area 3 – 4 times/day • Wash hands with soap and water (unless applying to hands, wait 30 min before washing) • Do not use heating pad, do not bandage, avoid direct exposure to heat or sunlight • Patch: avoid contact with face, scalp, mouth, eyes, wounds, damaged or irritated skin, or mucous membranes • Apply patch topically to clean and dry affected area. Wash hands with soap and water after applying. May cut patch to desired size. Do not use within 1 hour prior to bath or immediately after bathing/shower. Do not use heating pad, compression device or bandage. • Side Effects/Warnings: • For external use only Redgessofskint • Application site burning, pain, or erythema • OTC labeling: Transient burning may occur and generally disappears after several days. go H NSAIDS – TOPICAL • Pharmacologic Category: Nonsteroidal anti-inflammatory (NSAID) • MOA: inhibits production of prostaglandins (PGs) by inhibiting two cyclooxygenase (COX) I enzymes • Warning/Contraindication: • Contraindicated in the setting of coronary artery bypass graft surgery • Increase risk of serious cardiovascular thrombotic events (less likely with topical formulations due to minimal systemic absorption) • Increased risk of serious GI adverse reactions/bleeding (less likely with topical formulations due to minimal systemic absorption) • Use lowest effective dose for the shortest duration of time NSAIDS – TOPICAL a • Diclofenac sodium 1% gel (available as OTC, RX): Voltaren gel, Aleve Arthritis Gel • Dose: • Lower extremities: 4 grams AAA QID • Upper extremities: 2 grams AAA QID • If multiple joints are treated, max is 32 grams/day • If used for self-medication: • Max is 16 grams/day for single lower extremity joint • Max is 8 grams/day for single upper extremity joint • Do not use > 21 days or > 2 body parts at same time NSAIDS – TOPICAL • Diclofenac sodium 1.5% liquid (RX): Pennsaid • Dose: • Apply 40 drops to each affected knee up to QID • Apply 10 drops at a time, rub drops in, apply remainder of dose • Diclofenac sodium 2% liquid (RX): Pennsaid • Dose: • Apply 40 mg (2 pump actuations) to each affected knee up to BID gw Jet ORAL THERAPY NSAIDs Acetaminophen Tramadol Glucosamine and chondroitin Duloxetine Att Acetomenophire NSAIDS – ORAL First • Oral NSAIDs are initial DOC for OA treatment • Use lowest effective dose for shortest duration of time • Warning/Contraindication: • Contraindicated in the setting of coronary artery bypass graft surgery • Increase risk of serious cardiovascular thrombotic events • Increased risk of serious GI adverse reactions/bleeding • Avoid in patients with renal impairment NSAIDS – ORAL • Monitoring: • Renal functioning • BUN/Scr • Hgb/Hct • Blood pressure • Adverse Drug Reactions: • GI bleed • Cardiovascular events • Renal Impairment • Nausea NSAIDS - ORAL celebrex Diclofenac Etodone meloxicom Naburatore • Increased COX-2 selectivity results in lower risk of GI complications Brand Generic Dose Selectivity Advil, Motrin Ibuprofen 1,200 - 3,200 mg/day in 3 - 4 divided doses COX-1 and COX-2 Non-selective Aleve, Naprosyn Naproxen 220 – 550 mg BID COX-1 and COX-2 Non-selective Indocin Indomethacin 25 mg – 50 mg TID COX-1 and COX-2 Non-selective Piroxicam Feldene 20 mg daily COX-1 and COX-2 Non-selective Celebrex Celecoxib 100mg BID or 200mg daily Highest COX-2 Selectivity Voltaren XR, Cataflam IR Diclofenac 100-200mg daily 50-75mg BID COX-2 Selectivity Lodine Etodolac 400-500mg BID COX-2 Selectivity Mobic Meloxicam 15mg daily COX-2 Selectivity Relafen Nabumetone 500-1000mg 1-2 times a day COX-2 Selectivity CHECKPOINT untress inhibitprostaglandins M What is the primary mechanism of action of NSAIDs? A. B. C. D. Enhancement of cartilage repair Inhibition of prostaglandin synthesis Stimulation of opioid receptors Inhibition of COX-1 and COX-2 enzymes inhibitoxford CHECKPOINT Hypotension no peptic safe What is a potential side effect of long-term NSAID use? A. B. C. D. Osteoporosis Hypertension Peptic ulcer disease Peripheral neuropathy CHECKPOINT toRiskofsystemic SE What is an advantage of using topical NSAIDs over oral NSAIDs? A. B. C. D. Greater risk of gastrointestinal side effects Reduced risk of systemic side effects Application to multiple locations Decreased risk of liver toxicity ACETAMINOPHEN • Pharmacologic Category: Analgesic, nonopioid • MOA: blocks prostaglandin synthesis from arachidonic acid by inhibiting COX-1 and COX-2 enzymes • Contraindication: for OTC labeling, do not use with other drug products containing acetaminophen or if allergic to acetaminophen ACETAMINOPHEN • Side Effects: acute hepatoxicity, risk of hepatic toxicity behind maximum daily limit and previous history of excessive alcohol intake • Formulations: • Available as OTC tablet, liquid • Tablet: 325 mg, 500 mg, 650 mg • Liquid: 160 mg/5 mL ACETAMINOPHEN • Dose: • Regular strength (325 mg/tablet): • Take 2 tablets (650 mg) every 4 to 6 hours as needed • Maximum daily dose: 10 tablets/day (3.25 g/day). • Extra strength (500 mg/tablet): • Take 2 tablets (1 g) every 6 hours as needed • Maximum daily dose: 6 tablets/day (3 g/day). • Extended release (650 mg/tablet): • Take 2 tablets (1.3 g) every 8 hours as needed • Maximum daily dose: 6 tablets/day (3.9 g/day) CHECKPOINT What is potential side effect associated with acetaminophen use? A. B. C. D. Liver toxicity Increased risk of bleeding Renal impairment Gastrointestinal irritation Livertoxicity CHECKPOINT inhibitiondsom my What is the primary mechanism of action of acetaminophen? A. Enhancement of cartilage repair B. Stimulation of prostaglandin synthesis C. Stimulation of opioid receptors D. Inhibition of COX-1 and COX-2 enzymes enzymes TRAMADOL • Pharmacologic Category: Opioid • MOA: • Dual mechanism of action • Binds at µ-opioid receptors and inhibiting noradrenaline and serotonin re-uptake • Administration: • Can be taken with acetaminophen or oral NSAID therapy • Dose: • Chronic pain: • Immediate release: no established dosing regimen • 25 to 50 mg Q6H PRN, may increase dose by 50 to 100 mg every 4 to 6 hours (maximum: 400 mg/day) • Extended release: 100 mg QD, titrate up by 100 mg/day once every 5 days up to max 300 mg/day TRAMADOL • Contraindication: Hypersensitivity to tramadol, opioids, or any ingredients of the formulation • Side Effects: • Constipation • Dyspepsia • Nausea • Dizziness • Drowsiness • Headache • DDI: • Concurrent use with other serotonergic medications NON-TRAMADOL OPIOIDS Fyi • Non-tramadol opioids are conditionally recommended against • Risk of dependence and drug diversion CHONDROITIN • Conditionally recommended the use in the management of hand QA • Strongly recommended against the use in the management of knee, and hip OA • Often found in combination with Glucosamine GLUCOSAMINE • Strongly recommended against the use in the management of hand, knee, and hip OA DULOXETINE • Pharmacologic Category: Antidepressant, Serotonin/Norepinephrine Reuptake Inhibitor • MOA: inhibits reuptake of serotonin and norepinephrine (NE) in the CNS • Conditionally recommended for patients with knee, hip, and/or hand QA • Use studied primarily in the knee • Has efficacy with sand alone use or in combination with NSAIDs DULOXETINE • Dose: • Initial: 30 mg QD for 1 week, then 60 mg QD • Max dose: 60 mg QD • Contraindication: • Use of monoamine oxidase (MAO) inhibitors (concurrent use or within 14 days od d/c) • Initiation of MAO inhibitor within 5 days of d/c duloxetine • Initiation of duloxetine in linezolid or IV methylene blue • Side Effects: Gantibi • Weight loss, nausea, constipation, vomiting INJECTIONS HYALURONIC ACID • Acts as a natural lubricant and cushion in the joints • Intra-articular injection would result in increased lubrication • Clinical effectiveness has yielded mixed results • Listed as Conditionally Recommended Against for Hand and Knee OA • Strongly Recommended Against in Hip OA INJECTIONS - INTRA-ARTICULAR GLUCOCORTICOID • Strongly recommended for patients with knee or hip OA • Conditionally recommended for patients with hand OA • Demonstrated short term relief in knee OA • Recommended to use ultrasound guidance when injecting into the hip • Common examples: • Methylprednisolone acetate • Triamcinolone acetonide CHECKPOINT Which Intra-articular injections is commonly used for symptom relief? A. B. C. D. Corticosteroids Methotrexate Platelet-rich plasma Botulinum toxin CHECKPOINT What is a common surgical intervention for severe osteoarthritis? A. B. C. D. Joint fusion Arthroscopy Joint replacement Ligament repair