CASE STUDY ON OSTEOARTHRITIS

this slides provides the case study on osteoarthritis for pharm d students and m pharm pharmacy practice students

1. OSTEOARTHRITIS ANIL DHAKAL

2. INTRODUCTION Osteoarthritis (OA) is the most common form of arthritis, with 30 million Americans affected. In the past, OA was thought to result from years of wear and tear on joints. However, doctors now see that OA has multiple causes and is a disease of the entire joint.

3. What Happens in Osteoarthritis? In healthy joints, cartilage covers the end of each bone. It provides a smooth, gliding surface for joint motion and acts as a cushion between the bones. In OA, this cartilage breaks down, leading to pain, swelling and problems using the joint. Changes also occur in the underlying bone. Bony growths called spurs develop on the edges of the joint. Bits of bone or cartilage may float loosely in the joint space. The membrane lining the joint (the synovium ) often becomes inflamed, leading to joint swelling.

4. While there are estimated to be more than 100 types of arthritis, osteoarthritis (OA) is the most common form of arthritis, affecting 32.5 million US adults 43% of people with OA are 65 or older and 88% of people with OA are 45 or older.2 Annua l incidenc e of knee O A i s highest between 55 an d 64 years old Among people younger than 45, OA is more common among men; above age 45, OA is more common in women 78% of individuals with OA are non-Hispanic whites.However , within their own race/ethnic groups, non-Hispanic black and Hispanic populations have higher rates of OA than non-Hispanic whites. Osteoarthritis is the second most common rheumatologic problem and it is the most frequent joint disease with a prevalence of 22% to 39% in India. EPIDIOMOLOGY

5. • Persistent or recurring pain, aching or tenderness. • Stiffness and limited range of motion. • Mild swelling. • Clicking or cracking sounds. • Enlargement of or changes to the shape of a joint S YMPTOMS

6. Older age Sex Obesity Injuries to the joint Certain activities Genetics Bone and soft tissue deformities RISK FACTORS

7. OA is a disease of the entire joint sparing no tissues. The cause of OA is an interplay of risk factors (mentioned above), mechanical stress, and abnormal joint mechanics. The combination leads to pro-inflammatory markers and proteases that eventually mediate joint destruction. The complete pathway that leads to the destruction of the entire joint is unknown. Usually, the earliest changes that occur in OA are at the level of the articular cartilage that develops surface fibrillation, irregularity, and focal erosions. These erosions eventually extend down to the bone and continually expand to involve more of the joint surface. On a microscopic level, after cartilage injury, the collagen matrix is damaged, causing chondrocytes to proliferate and form clusters PATHOPHYSIOLOGY

8. . A phenotypic change to hypertrophic chondrocyte occurs, causing cartilage outgrowths that ossify and form osteophytes . As more of the collagen matrix is damaged, chondrocytes undergo apoptosis. Improperly mineralized collagen causes subchondral bone thickening; in advanced disease, bone cysts infrequently occur. Even rarer, bony erosions appear in erosive OA. There is also some degree of synovial inflammation and hypertrophy, although this is not the inciting factor as is the case with inflammatory arthritis. Soft-tissue structures (ligaments, joint capsule, menisci) are also affected. In end-stage OA, both calcium phosphate and calcium pyrophosphate dihydrate crystals are present. Their role is unclear, but they are thought to contribute to synovial inflammation.

9. Pain Stiffness Tenderness Loss of flexibility Grating sensation Bone spurs Swelling CLINICAL PRESENTATION

10. COMPLICATIONS Rapid, complete breakdown of cartilage resulting in loose tissue material in the joint ( chondrolysis ). Bone death ( osteonecrosis ). Stress fractures (hairline crack in the bone that develops gradually in response to repeated injury or stress). Bleeding inside the joint. Infection in the joint.

11. DIAGNOSIS Physical Examination X-rays MRI Blood tests Joint fluid analysis

12. MANAGEMENT Analgesics: Analgesics are medications used for pain relief. Acetaminophen is a non- opioid (or non-narcotic) analgesic that doesn’t reduce inflammation or swelling, but it is helpful when pain is the main problem. NSAIDs: Nonsteroidal anti-inflammatory drugs help reduce joint pain, stiffness and swelling. NSAIDs available over the counter are aspirin, ibuprofen and naproxen sodium. Oral and topical prescription NSAIDs are also available to treat OA.. Injectables : Joint injections are often used by people with OA. Corticosteroids may be injected into an affected joint to relieve pain and swelling. Hyaluronic acid therapy involves injecting the joint with a substance found naturally in joint fluid that helps to lubricate and cushion the joint.

13. Antidepressants Some antidepressants relieve arthritis pain. Duloxetine has been approved by the FDA for use in treating chronic musculoskeletal pain. Topical Pain Relievers Topical pain relievers are available as creams, gels, patches, rubs or sprays that are applied to the skin over a painful joint. They may contain combinations of salicylates , skin irritants and local anesthetics to relieve pain. Some NSAIDs are available by prescription for topical use as well. Nutritional Supplements Glucosamine and chondroitin sulfate are nutritional supplements that many people believe offer relief from OA pain. Studies regarding their effectiveness have mixed results. Avocado soybean unsaponifiables (ASU) are supplements shown in some studies to slow the progression of OA and improve symptoms. Be sure to talk to your doctor about possible benefits and risks before taking these – or any – supplements.

14. Non-Pharmacological Therapy: Strengthening exercises build muscles around painful joints and helps to ease the stress on them. Range-of-motion exercise or stretching helps to reduce stiffness and keep joints moving. Aerobic or cardio exercises help improve stamina and energy levels and reduce excess weight. Balance exercises help strengthen small muscles around the knees and ankles and help prevent falls. Weight Loss: Excess weight puts additional force and stress on weight-bearing joints, including the hips, knees, ankles, feet and back, and fat cells promote inflammation. Losing extra weight helps reduce pain and slow joint damage. Every pound of weight lost removes four pounds of pressure on lower-body joints. Physical Therapies and Assistive Devices : Physical therapists, occupational therapists and chiropractors can provide: Specific exercises to help stabilize your joints and ease pain. Information about natural treatments and products that can ease pain. Instruction to make movement easier and to protect joints. Braces, shoe inserts or other assistive devices.

15. TOTAL KNEE REPLACEMENT

16. CASE STUDY PAST MEDICATION : K/C/O SHTN on irregular treatment MEDICATIONS NONE FAMILY HISTORY NONE AGE: 65 years GENDER: FEMALE Ward: Orthopaedics ward Chief complaints: Pain over right knee x 1 month, Difficulty in walking, squatting and climbing stairs

17. OBJECTIVE O/E: Patient conscious, oriented , afebrile BP: 140/ 80 mm Hg PR: 72 beats/min CVS: NAD RS: NAD CNS: NFND Right knee, swelling + Medial joint line tenderness + ROM - Restricted and painful

18. TREATMENT GIVEN DRUG DOSE FREQUENCY TAB. Diclofenac 100 mg 1-0-1 TAB. Ranitidine 150 mg 1-0-1 TAB. BC/ Cal/ Vit C 0-1-0 INJ. Diclofenac 2cc IM SOS DAY ON EXAMINATION DRUGS DOSE FREQUENCY 2 Right knee, swelling + CST TAB. Losartan 50 mg 0-0-1 T AB . Amlodipine 2.5 mg 1-0-0

19. DAY ON EXAMINATION DRUGS DOSE FREQUENCY 3 T - 98.4 F TAB. Diclofenac TAB. Ranitidine TAB. BC/Cal TAB. Losartan T AB . Amlodipine 100 mg 1-0-1 PR- 80/mt RR - 20/mt BP- 160/90 mmHg SpO2- 92% 150 mg 50 mg 2.5 mg 1-0-1 0-1-0 0-0-1 1-0-0 4 T - 98.4 F PR- 76/mt RR - 20/mt BP- 140/80 mmHg SpO2- 96% Tenderness + CST

20. DAY ON EXAMINATION DRUGS DOSE FREQUENCY 5 T - 98.4 F PR- 84/mt RR - 22/mt BP- 150/90 mmHg SpO2- 95% CST 6 T - 98.4 F PR- 86/mt RR - 20/mt BP- 120/80 mmHg SpO2- 96% CST

21. DAY ON EXAMINATION DRUGS DOSE FREQUENCY 7 T - 98.2 F PR- 88/mt RR - 22/mt BP- 120/70 mmHg SpO2- 96% T AB . Paracetamol TAB. Calcium TAB. Losartan 500 mg 50 mg 2.5 mg 1-0-1 1-0-1 1-0-1

22. INTERVENTION T otal Kne e Arthroplast y shoul d have been done i n thi s patient. IFT should have been initiated for the patient along with pharmacological treatment for both knees. Pain assessment scale can be used to assess the severity of the condition and pain medications can be given accordingly.

23. MY PLAN DRUGS DOSE FREQUENCY TAB. Diclofenac 100 mg 1-0-1 TAB. Ranitidine 150 mg 1-0-1 TAB. BC/ Calcium 0-0-1 T AB . Amlodipine 2.5 mg 1-0-0

24. Monitoring parameters DRUGS BRAND NAME MONITORING P ARAMETERS Diclofenac Voltaren-XR CBC, BP, LFT, RFT Ranitidine Rantac LFT, RFT Amlodipine Amlong BP, serum potassium

25. Patient counsceling Osteoarthritis occurs when the cartilage that cushions and protects the ends of your bones gradually wears away. This leads to pain and stiffness that worsens over time, making it difficult to do daily activities. Clinical Presentation includes pain, stiffness, tenderness, loss of flexibility, grating sensation, bone spurs, swelling Osteoarthritis is a degenerative disease that worsens over time, often resulting in chronic pain. Joint pain and stiffness can become severe enough to make daily tasks difficult. Depression and sleep disturbances can result from the pain and disability of osteoarthritis

26. Patient counsceling REGARDING DRUGS: The patient should be counselled on the use of the drug and on medication adherence. The patient is advised not to take double the dose and in case of missed dose the patient should continue the next dose. In case of any side effects the patient is advised to stop the medication and contact the physician. To prevent heartburn and acid indigestion, take Ranitidine 30-60 minutes before eating food or drinking beverages that can cause indigestion. Amlodipine : You may get drowsy or dizzy. Do not drive, use machinery, or do anything that needs mental alertness until you know how this medication affects you. Do not stand up or sit up quickly, especially if you are an older patient. This reduces the risk of dizzy or fainting spells.

27. Patient counsceling REGARDING LIFESTYLE MODIFICATIONS: Weight management and exercise play a key role in managing OA. Losing weight can help reduce the pressure on the knee. Exercise keeps the knee muscles strong and helps support the knee joint. A doctor or physical therapist may recommend switching from high-impact exercises — like running — to low-impact ones, like swimming and water aerobics. Other suitable options include tai chi, walking, cycling, and stretching exercises. Ice and heat packs Avoid smoking Follow a healthful diet Find a suitable balance between activity and rest Establish regular sleeping patterns Learn how to manage stress

28. references Osteoarthritis - OrthoInfo - AAOS (2022). Available at: https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis/ OA Prevalence and Burden - Osteoarthritis Action Alliance (2022). Available at: https://oaaction.unc.edu/oa-module/oa-prevalence-and-burden/ Michael, J., Schlüter-Brust , K. and Eysel , P. (2010) "The Epidemiology, Etiology, Diagnosis, and Treatment of Osteoarthritis of the Knee", Deutsches Ärzteblatt international . doi : 10.3238/arztebl.2010.0152. Osteoarthritis - Symptoms and causes (2022). Available at: https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925

29. Osteoarthritis: Symptoms, Causes and Treatment (2022). Available at: https://my.clevelandclinic.org/health/diseases/5599-osteoarthritis Morgan, K. and Ahlawat , R. (2021) "Ranitidine", StatPearls Publishing , p. Available at: https://www.ncbi.nlm.nih.gov/books/NBK532989/ Diclofenac : Indication, Dosage, Side Effect, Precaution | CIMS India (2022). Available at: https://www.mims.com/india/drug/info/diclofenac?type=full&mtype=generic#:~:text=Monitoring %20Parameters%20Monitor%20CBC%2C%20blood,ulceration%2C%20perforation%20or%20ha emorrhage%3B%20mental Ranitidine Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing - WebMD (2022). A vailable at: https://www.webmd.com/drugs/2/drug-4091-5250/ranitidine-oral/ranitidine-75-mg-oral/details#:~ :text=Swallow%20the%20tablet%20whole%20without,unless%20directed%20by%20your%20do ctor .

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