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Osteoarthritis - Learning Objectives

Integrated Pharmacotherapy 1 (Purdue University)

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Osteoarthritis

 Describe normal joint physiology, etiology, incidence, pathophysiology, clinical

presentation, potential complications and prognosis of OA
o Degenerative changes occur in cartilage and associated bone
o Characterized by increased destruction and subsequent proliferation of
cartilage and bone; regenerated articular surfaces do not possess the
same qualities and architecture as original joint
o Observed more commonly in older patients
 Almost 85% of patients older than 75 (severity increases with
age)
 Females more at risk than males
o Joints most commonly affected
 Distal interphalangeal joint
 Hips
 Knees
o OA vs. RA

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o Risk factors for OA

 Increasing age
 Obesity
 Congenital/anatomical defects
 Muscle weakness
 Female gender
 Repetitive stress
 Major joint trauma
 Heredity
o Clinical Manifestations/Presentation of OA
 Pain that worsens w/ activity
 AM stiffness is brief (< 1 hour)
 Crepitus (crackling sound)
 Inflammation is observed in more advanced disease and pain at
rest
 Asymmetric involvement
 Muscle atrophy
 No systemic symptoms
 Instability of weight bearing joints
 Herberden’s nodes
 Bouchard’s nodes
 Describe therapeutic use of drugs used to treat OA, including drugs, dosing,
MOAs, place in therapy, adverse effects, warnings & contraindications and
monitoring
o Goals/Desired outcomes of therapy
 Relief of pain/discomfort
 Maintain function and strength of joint
 Prevent deformities and progressive changes
o Step 1: non-pharmacologic therapy
 Psychological support & education
 Rest, physical activity & exercise
 Heat/ice
 PT and/or OT

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 Weight loss
o Step 2: pharmacologic therapy
 Acetaminophen (2-4 week trial)
 MOA: inhibits synthesis of prostaglandins
 Dose: 1g q4-6 hours
 Max dose: 3g/day
 Patients at risk for hepatotoxicity: heavy alcohol intake,
pre-existing liver disease, monitor ALT/AST annually if on
routine doses
 Topical Therapy
 Menthol/Camphor/Oil of Wintergreen
o Topical counter irritant
o Apply sparingly
o Dose: apply multiple times/day
o Avoid contact with eyes
 Capsaicin Cream
o MOA: depletes substance p
o Dose: apply sparingly to affected joints 2-4x/day
o Wait 2-4 weeks to evaluate maximum effect
o Educate patient about proper application
procedures
o Adverse effects: burning, stinging and redness
 Diclofenac Topical Gel 1%
o MOA: local inhibition of COX-2 enzymes
o Dose: apply to joint QID, 16g max at any one joint
per day
o Not recommended in combo w/ systemic NSAID
therapy
o Adverse: pruritus, burning, pain & rash
 Diclofenac Topical Solution 1.5%
o Dose: 40 drops to each knee QID, apply 10 drops at
a time
o Garlic smell/taste, DMSO vehicle
 Glucosamine/Chondroitin
o MOA: stimulate proteoglycan synthesis from
articular cartilage
o Dose
 Glucosamine: 500mg PO TID
 Chondroitin: 400mg PO TID
o Concern about standardization of products
o Some concern about use in patients with DM, HTN,
hyperlipidemias due to increased insulin
resistance
o Adverse effects: gas, bloating, cramping, nausea

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o Step 3
 NSAIDs
 MOA: blocks prostaglandin synthesis by inhibition of COX
enzymes
 Selection based on cost, side effects, dosing convenience,
other medical conditions, other meds, risk of bleeding,
risk of peptic ulcer disease (PUD)
 Dosing
o Analgesic: 220mg q8-12hrs
o Anti-inflammatory: 440mg q8-12hrs
 1-2 week trial for pain and 2-4 week trial if inflammation
exists
 Major adverse effects
o GI upset/ulcers
o Bleeding
o Renal dysfunction
o Effects on BP
 Patients at greatest risk for ADRs from NSAIDs
o Dose dependent
o Elderly
o History of GI bleed/PUD
o Anticoagulant therapy
o Antiplatelet therapy
o Glucocorticoids
o Patients with CHF, HTN, renal dysfunction and
dehydration are at increased risk of
nephrotoxicity
 Monitor
o BP
o Symptoms of edema or weight gain
o BUN/SCr every 3 months
o Hgb/Hct every 6-12 months
o Signs of dehydration
 Consider
o COX-2 inhibitor (celecoxib): 100-200mg
o NSAID + PPI: Vimovo (naproxen + esomeprazole)
o NSAID + misoprostol: Arthrotec (Diclofenac +
misoprostol)
 Potential benefits of COX-2 inhibitors: once daily dosing
o Lower incidence of severe GI bleeding
 Potential risks associated with COX-2 inhibitors
o Increased risk of CV disease
o Increased costs
o Same impact on renal functions and INR

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o Step 4
 Opioid Analgesics
 Used PRN for breakthrough pain
 Watch total dose of APAP closely
 Dosing: start low/go slow, use long acting SR and short
acting IR
 Adverse: nausea, somnolence, constipation, dizziness
 Tramadol
 MOA: affinity for μ receptor; inhibits norepinephrine and
serotonin
 Dose: 25-50mg q4-6hrs, max: 400mg/day
 Adverse effects/precautions: nausea, vomiting, dizziness
and constipation
 Intra-articular corticosteroid injections
 Only used for isolated joints
 No more often than q4-6 months
 Peak pain relief in 7-10 days
 Hyaluronate injections
 MOA: temporarily increase viscosity of joint
 Dose: injected once weekly x3-5 weeks into joint (minor
swelling)
 Max benefit in 8-12 weeks
 Patients who don’t tolerate other treatments or are not
candidates for surgery
 Adverse effects: local, minor swelling
o Step 5
 Joint Resurfacing Surgery and Joint Replacement Surgery
 Relives pain
 Restores function to joint
 Monitoring Parameters for Patients with OA
 Pain at rest
 Joint stability and function
 Risk of fall
 ROM
 X-rays
 Degree of disability
 Weight
 ADRs from medications
 Compliance with non-drug measures
 QOL issues

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 Develop a pharmacotherapy plan for OA patient, including pharmacologic and

nonpharmacologic therapy, monitoring, expected/desired outcomes & patient
education

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