From: Subject: Best Dx/Best Rx: Osteoarthritis Date: Wed, 3 Jun 2009 21:45:35 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_023B_01C9E494.A05BBFF0" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_023B_01C9E494.A05BBFF0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx1510.htm Best Dx/Best Rx: Osteoarthritis



Osteoarthritis

Christopher Wise, M.D.
Medical College of = Virginia at=20 Virginia Commonwealth University

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy


Definition/Key=20 Clinical Features

  • Degeneration of articular cartilage and = reactive changes=20 in surrounding bone and periarticular tissue=20
  • Associated with aging, obesity, bone density, = hormonal=20 status, nutritional factors, joint dysplasia, trauma, occupational = factors,=20 hereditary factors=20
  • Articular pain=97hands, hips, knees, = shoulders, cervical=20 or lumbar spine=20
    • Worsens with activity, improves with = rest=20
    • Usually chronic=20
    • Worsens gradually over time =
  • Osteophytes (bone spurs)=20
  • Stiffness in morning and after sitting for = extended=20 periods=20
  • Mild/moderate swelling=20
  • Crepitus=20
  • Bony enlargement=20
  • Periarticular tenderness=20
  • Possible synovial effusions (particularly in=20 knee)=20
  • Deformity, limited range of motion, loss of = function,=20 instability after many years of disease
3D""=20=20 bac= k to=20 top

Differential = Diagnosis

  • Injury=20
  • Inflammatory conditions=20
    • Rheumatoid arthritis=20
    • Ankylosing spondylitis=20
    • Reiter syndrome=20
    • Psoriasis=20
    • Polymyalgia rheumatica
  • Malignancies=20
    • Metastatic breast cancer=20
    • Lung cancer=20
    • GI cancer=20
    • Myeloma
  • Bone disease=20
    • Osteonecrosis=20
    • Paget disease=20
    • Osteochondritis=20
    • Osteoporosis
  • Metabolic arthritis=20
    • Gout=20
    • Calcium pyrophosphate deposition = disease=20
    • Hemochromatosis=20
    • Ochronosis=20
    • Wilson disease=20
    • Acromegaly
  • Tendinitis=20
    • Bursitis=20
    • Peripheral neuropathies
  • Hereditary=20
    • Perthes disease=20
    • Chondrodysplasia
3D""=20=20 bac= k to=20 top

Best=20 Tests

  • History and physical examination may be = sufficient for=20 diagnosis

Radiography: Characteristic = Features

  • Joint space narrowing, often = asymmetrical=20
  • Films of knees taken during weight bearing are = helpful=20
  • Subchondral bone sclerosis=20
  • Subchondral cysts=20
  • Osteophytes=20
  • Subluxation or fusion of severely affected = joints=20
  • Central erosion in fingers

Lab Studies

  • Useful only to rule out other diagnoses =
  • ESR, rheumatoid factor, uric acid usually = normal=20
  • Synovial fluid noninflammatory=97no crystals = and few=20 leukocytes
3D""=20=20 bac= k to=20 top

Best=20 Therapy

Nonpharmacologic

  • Exercise (focus on muscle strengthening, = especially in=20 knees)=20
  • Weight loss=20
  • Ensure adequate dietary calcium and vitamins C = and=20 D=20
  • Patellar taping, wedged insoles, bracing, = canes, or=20 crutches

Pharmacologic Therapy for = Osteoarthritis

  • Acetaminophen: first choice for most patients; = doses=20 should be limited in patients with exposure to potentially hepatotoxic = substances, especially alcohol=20
    • Dose: 3,000=964,000 mg/day=20
    • Cost/mo: $6.50
  • NSAIDs: alternative; usually provide 50%=9675% = relief;=20 risk of gastric ulcers and bleeding=20
    • Ibuprofen=20
      • Dose: 600 mg q.i.d.=20
      • Cost/mo: $12.99
    • Naproxen=20
      • Dose: 500 mg b.i.d.=20
      • Cost/mo: $17.99
    • Piroxicam=20
      • Dose: 20 mg q.d.=20
      • Cost/mo: $7.99
    • Sulindac=20
      • Dose: 100 mg b.i.d.=20
      • Cost/mo: $21.22 =
  • Selective cyclooxygenase-2 (COX-2) inhibitors: = efficacy=20 equal to generic NSAIDs; can reduce GI complications=20
    • Celecoxib=20
      • Dose: 100=96200 mg b.i.d.=20
      • Cost/mo: $80.00 =
  • Acetaminophen/codeine: moderately effective; = generally=20 avoided but useful in selected patients; use with caution in elderly=20 patients=20
    • Dose: one to two tabs/day=20
    • Cost/mo: $15.98
  • Topical capsaicin: transient effect; may be = useful in=20 some patients, especially for hands and knees=20
    • Dose: 0.025% cream three to four times = daily=20
    • Cost/mo: 8 oz/$63.99
  • Tramadol: may be as effective as acetaminophen = +=20 codeine=20
    • Dose: 50 mg, two to four tabs/day=20
    • Cost/mo: $56.99
  • Triamcinolone acetonide: for knee OA and = effusion=20
    • Dose: 10=9640 mg intra-articular injections = every 3=20 mo=20
    • Cost/mo: not available
  • Sodium hyaluronate: relieves pain for several = months;=20 comparable to NSAIDs; lasts longer than intra-articular = steroids=20
    • Dose: 3=965 weekly intra-articular=20 injections

Surgery

  • Arthroscopic debridement of the knee=20
  • Realignment of a degenerative knee=20
  • Total joint replacement

July=20 2006

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