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Leik Review--Degenerative Joint Disease (Osteoarthritis):
Terms in this set (10)
--Arthritis occurs when the cartilage covering the articular surface of joints becomes damaged.
--Large weight bearing joints (hips and knees) and the hands are the most commonly affected.
Risk factors for the development of arthritis:
--Overuse of joints
--Positive family history
Goal of treatment:
--Preserve joint mobility and function.
--Minimize disability and protect joint.
Classic case of Osteoarthritis:
--Gradual onset (over years).
--Early-morning joint stiffness with inactivity.
--Shorter duration of joint stiffness ( < 15 minutes) compared to rheumatoid arthritis (RA).
--Pain aggravated by overuse of joint.
--During exacerbations, involved joint may be swollen and tender to palpation.
--May be one sided (such as right hip only).
--Absence of systemic symptoms (not a systemic inflammatory illness like RA).
Heberden's nodes--bony nodules on the distal interphalangeal joints (DIP).
Bouchard's nodes--bony nodules on the proximal interphalangeal joints (PIP).
--Exercise (with care) at least 3 times a week.
--Isometric exercises to strengthen quadriceps muscles (knee OA).
--Exercise (swimming, walking, biking); resistance-band exercises.
--Avoid aggravating activities.
--Cold or warm packs.
--Walking aids. (Patellar taping by physical therapy--reduces load on knees)
--Alternative medicine: Glucosamine supplements, SAM-e, Tai-Chi exercises, accupuncture.
--Join Arthritis Self-Management Program (ASMP) with physical therapy.
Treatment plan (adapted from the American College of Rheumatology):
--First line medication is acetaminophen 325-650 mg po every 4-6 hours (max of 4 g per day) PRN.
--OR Tylenol Extra Strength 500-1000 mg po every 6 hours (maximum 6 tablets per day) PRN.
--If no relief with high-dose acetaminophen, switch to a short-acting NSAID.
--Start with Ibuprofen (Advil) 1-2 tablets every 4-6 hours or Naproxen (Aleve) BID or Anaprox DS 1 tablet every 12 hrs PRN.
--For added GI protection, add a PPI (omeprazole) or misoprostol (Cytotec).
--If pt is at high risk for both GI bleeding and CV side effects, avoid NSAIDs.
--Age > 75: use topical NSAIDs for treatment vs oral.
--Rule out osteoporosis. Order bone density scanning.
--Avoid opioid analgesics if possible, especially if the pt is a recovering addict/alcoholic.
GI bleeding risk factors:
--History of uncomplicated ulcer.
--NSAID: Diclofenac gel (Voltaren gel); apply to painful areas and massage well into skin BID.
--Capsaicin cream: apply to painful area QID. Avoid contact with eyes/mucous membranes.
--Do not sure on wounds/abraded skin.
--Avoid bathing or showering after use so that it's not washed off.
--Capsaicin is from chili peppers. It's also used to treat neuropathic pain (eg, post shingles).
NSAIDs and risks:
--Highest risk for GI bleeding: ketorolac (Toradol) and piroxicam (Feldene).
--Lowest risk for GI bleeding: Ibuprofen, celecoxib (Celebrex)
--Highest risk for CV events: Diclofenac and celecoxib at higher doses.
--Lowest CV risk: Naproxen
Exam tips from Leik:
--Distinguish classic presentation differences between RA and OA.
--With RA, the joint stiffness lasts longer, involves multiple joints, and has a symmetrical distribution. RA is accompanied by systemic symptoms like fatigue, fever, normocytic anemia, etc.
--Heberden's and/or Bouchard's nodes have appeared many times on the exam (boards). Memorize the location of each.
--Types of treatment methods used for DJD: Analgesics, NSAIDs (po and topical), steroid injection to inflammed joints (NO systemic/oral steroids), surgery (ie, joint replacement).
--Do not confuse OA treatment with RA treatment.
--Treatment for RA includes all DJD treatment methods plus systemic steroids, antimalarials (Plaquenil), antimetabolites (methotrexate), biologics (Humira, Enbrel).
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