Treatment Of Osteoarthritis(Oa), Gout, And Ankylosing Spondylitis

Front 1

What is Osteoarthritis(OA)?

Back 1

-Thee most prevelent rheumatic dz
-Increases with age
-50% over 65, and almost everyone by 75

Front 2

How does OA present?

Back 2

-Slowly progressive and affects diarthrodial joints
-Minimal inflammation involved

Front 3

What body area does OA affect?

Back 3

-Articular cartilage
-subchondral sclerosis
-osteophyte production

Front 4

Clinical manisfestaions of OA?

Back 4

-Gradual onset of joint pain
-Stiffness
-Limitation of motion

Front 5

Risk factors of OA?

Back 5

Obesity
repetitive stress
low quadriceip strenght
advancing age
genetic factors

Front 6

Goals of OA tx

Back 6

1) educate the pt, caregivers and relatives
2) relive pain and stiffness
3) Maintain or improve joint mobility
4) mantain or improve the Quality of Life

Front 7

Pain management is the primary goal of OA tx. T or F?

Back 7

True

Front 8

Pharm tx OA:

Back 8

-DMARDS do not work
-Acetominophen up to 4 gms/days should be tried initially.
-Try NSAID if acetominophen ineffective

Front 9

Pharm tx OA:

Back 9

-Capsaicin (Zostrix)
-Glucosamine and Chondroitin

Front 10

Capsaicin:

Back 10

-Active ingredient of hot chili peppers
-Depletes substance P form afferent nicoreceptors
-Apply 2-4 times daily to affected joints
-Takes up to 2 weeks to work
-Advise pts to wash hands well after touching and do not get in eyes

Front 11

Glucosamine and Chondrotin (OA)

Back 11

-Stim Proteoglycan synthesis from articular carglige in vivo
-Excellent safety profile
-Well tol

Front 12

Gout?

Back 12

Is a Rheumaltologic DZ due to Uric Acid Crystals

Front 13

What is Uric Acid?

Back 13

-Waste product of Purine Metabolism

Front 14

Serum urate concentration with risk of Gout correlates with?

Back 14

-age, serum creatinine level, BUN, Male gender, BP, body weight, and alcohol intake.

Front 15

Solubility of Uric Acid (weak acid)?

Back 15

-7mg/dl at physiologic PH
pKa=5.5

Front 16

Risk of Gout increases with?

Back 16

-Increasing Uric acid levels but:
many pts will have normal levels of uric acid somw will never have an attack despite very high levels of Uric Acid.

Front 17

Bascically with Increased Uric Acids Levels?

Back 17

= increased Gout attack

Front 18

Drugs that cause Hyperuricemia and Gout?

Back 18

-Diuretics
-Nicotinic Acid
-Salicylates
-Ethanol
-Pyranzanmide
-Levodopa
-Ethambutol
-Cytotoxic Drugs
-Cyclosporine

Front 19

Presentation of Gout:

Back 19

Gout typically involves acute attacks of:
-arthritis
-nephrolithiasis
-gouty neuropathy
-aggregated deposits of Sodium Urate (Tophi) in cartligae, tendons, synovial membranes, and elsewhere.

Front 20

Tophi (with Gout)?

Back 20

Tophi= aggregated deposits of sodium Urate

Front 21

Acute Gouty arthritis?

Back 21

Most common form of Gout
-rapid onset of excruciating pain, swelling and inflammation.
Monoarticular at first then great toe, and then order of freq: insteps, ankles, heels, knees, wrists, fingers, and elbows

Front 22

TX of Gouty arthritis?

Back 22

-Indomethacin
-Naproxen
-Ibuprofen
-Sulindac
Indomethacin = most potent NSAID but very toxic too.

Front 23

Kidney stones?

Back 23

10-20% of pts with Gout.
Risk factors for Stones:
-excessive urinary excretion of uric acid, acidic urine, highly concentrated urine.

Front 24

TX Kidney stones with Gout?

Back 24

-Urine output 2-3 ml/day
-alkalinazation of Urine (PH 6-6.5)
-avoidance of purine rich foods
-moderation of protein intake
-reduction of urinary acid secretion

Front 25

Prevention of Kidney stones with Gout?

Back 25

-Allopurinol is the mainstay.
Prevents formation of Uric acid in bloodstream
-which prevents fromation of calculi

Front 26

Gouty Nephropathy
Two types?

Back 26

-Acute Uric acid Nephropathy
-Chronic Urate Nephropathy
* see notes

Front 27

For pts with myeloproliferative disorders undergoing chemotherapy-what is the Drug of choice?

Back 27

-Allopurinol
DOC to prevent Acute Nephropathy

Front 28

Tophaceous Gout?

Back 28

-late complication of hyperuricemia
-affects: base of great toe, helix of ear, olecranon bursa, Achilles tendon, knees, wrists, and hands.
See notes for more crap
Can lead to Carpal Tunnel syndrome*

Front 29

Labs of Tophaceous Gout?

Back 29

-Elevated serum uric acid levels
-overprod or underproduction of uric acid
-Excretion primarily renal(2/3) but also GI(1/3)
-Leukocytosis

Front 30

TX for Tophaceous Gout?

Back 30

1) Tx for acute attack:
-NSAIDS (no aspirin_
-Colchicine
-Intrarticular steriod
-Probencid
2) Prev of recurrent attacks
-Allopurinol
-ARBS(losartin) and Probencid increase urinary excretion of uric acid.

Front 31

Colchicine?
pg 512

Back 31

Tx for accute Gouty attacks
and prevention of recurrent attacks

Front 32

MOA Colchicine?

Back 32

MOA
-reduciton in lactic acid production by leukocytes, which results in a decrease in uric acid deposition, and a reduction in phagocytosis with abatement of inflammatory response

Front 33

ADX of Colchicine?

Back 33

Many:
Alopecia, N&V, Gi disturbances, diahrrea, agranulocytosis/aplastic anemia, alopecia

Front 34

Allopruinol(Zyloprim)

Back 34

Use: Prevention of recurrent attacks, prev of neuropathy from chemo, mgmt of pts with signs and sxms of primary or secondary gout.

Front 35

Allopruinol MOA

Back 35

-Xanthine oxidase inhibitor
-Prevents formation of Uric acid
-Lowers serum uric acid levels (goal <6)
-Results in a fall in both serum and urinary uric acid within 2-3 days-dose dependant

Front 36

Adverse effects of Allopruinol?

Back 36

-Severe rash(SJS,TEN)
-DC at first signs*
-Renal elimination
-Drink extra fluid to maintain dilute and neutral to alkaline urine.
Lactation-use caution

Front 37

Uricosuric acid?

Back 37

-increase renal clearance of uric acid by inhibit renal tubular reabsorption
-start low dose to avoid poss stone formation
-Maintain urin flow alk with Sodium bicarb first few days to reduce uric acid stone formation

Front 38

Probenicid?

Back 38

-Tx of hyperuricemia associated with Gout and Gouty arthritis

Front 39

MOA for Probenicid?

Back 39

Inhibits tubular reabsorption urate, thus increasing the urinary excretion of uric acid and decreasing serum urate levels.
ADVSE rxn:
Acute sxms at first, start Chochiicin or NSAID first
Hypersensit rxn
Preg cat B
Many rxns.

Front 40

Ankylosing Spondylitis?

Back 40

A rheumatic disease that causes arthritis of the spine and sacroiliac joints and can cause inflammation of the eyes, lungs, and heart valves

Front 41

Ankylosing Spondylitis

Back 41

-varies from intermittaent episodes of back paing and sever chronic dz that attacks spine, peripheral joints, and other body organs resulting in severe joint stiffness, loss of motion and deformity
-Genetic marker HLA-B27
-Predisp post bowel or UTI
-adolescents and young adult males
Most common is Native Amreicans**

Front 42

What is the most effective NSAID For AS?

Back 42

Indomethacin

Front 43

Hypnotic effects with Benzo's

Back 43

-Hyonosis is a characteristic of ALL sedatives/hypnotics if a large enough dose is given
--Goal induce sufficient drowsiness to induce sleep!

Front 44

Most sedative/hypnotics:?

Back 44

-decrease time to get to sleep (latency)
-increase time spent in stage 2 NREM sleep*
-dec time spent in REM sleep*
-both of those are good for sleep*

Front 45

Discontinuation of sedative/hypnotics results in?

Back 45

-REM Rebound
*Tolerance to effects on sleep patterns often develops post 2 weeks.

Front 46

Anasthesia effects of Benzo's?

Back 46

-Some agents will depress CNS to achieve stage III anesthesia
-*Benzo's are NOT suitable for induction of anesthesia
-Contribute to Postanesthetic respiratory depression

Front 47

Anticonvuslant effects of Benzo's?

Back 47

-some benzo's can inhibit the spread of seizure activity W/I the CNS
-Clonazepam
-Lorazepam
-Diazepam
-Nitrazepam

Front 48

Bezo tx should not exceed....?

Back 48

4 months
Short term for anxiety insomnial only!

Front 49

Advse RXN with Benzos?

Back 49

-majority of effects involve CNS
-drowsiness, sedation, psychomotor impairment, disinhibition, and ataxia
Many others see notes**

Front 50

Benzo's for anti-anxiety:?

Back 50

-Alprazolam (Xanax)
-Clonazepam(Klonopin)
-Diazepam (Valium)
-Lorazepam (Ativan)

Front 51

Benzo's for sleep:?

Back 51

-Temazepam (restoril)

Front 52

Non-benzo's anitanxiety?

Back 52

-Busiprone(Buspar)
-Zolpidem(Ambien)