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Osteoarthritis
Ahmed Shaman
Department of Clinical Pharmacy
[email protected]
1.Osteoarthritis (OA)
Osteoarthritis (OA)
• Most common form of arthritis (6% of adults)
• Degenerative disease of weight-bearing joints
– Joint pain, reduced range of motion and brief joint
stiffness after inactivity
– Hips & knees, but also hands
– Risk factors:
• Strongly related to age (10-15% of > 60 yo)
• Biomechanical stress (repetitive high-impact)
• Increased risk if overweight (10% per 1 kg > IBW)
Goals of Therapy for OA
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Educate patient & caregivers
Relieve pain
Maintain or restore mobility
Minimize functional impairment
Preserve joint integrity
Improve quality of life
Non-Pharmacologic Treatment of OA
• Patient education for lifestyle modification
– Aerobic exercise w/stretching & strength training
• Low impact isometric 3-4 times / week
– Yoga, water aerobics, walking
– Weight loss via diet and exercise
– Physical or occupational therapy
• Heat or cold treatments of affected joints
• Joint-replacement surgery
Pharmacologic Treatment of OA
First Line
• Acetaminophen (paracetamol)
– 1st line therapy due to effectiveness & safety
• As effective as NSAIDs for mild to moderate joint pain
– Up to 4 g (3 g safer) daily in divided doses
• Scheduled doses better, need 4-6 week trial
• NSAIDs
– Reasonable alternative after acetaminophen
– Usual NSAID problems (GI, renal, and
cardiovascular adverse events)
Other Pharmacotherapy for OA
First Line
• Topical therapy
– NSAIDs for superficial joints (Knees,hands)
– Capsaicin (takes 2 weeks)
• Steroids – Intraarticular
• Tramadol
– As effective as NSAIDs
– May be added to NSAIDs or Acetaminophen
Alternative Therapies for OA
Second Line
• Opioids for severe / refractory disease
• Duloxetine
– adjunctive treatment in patients with a partial
response to first-line analgesics
• Hyaluronic Acid Intra-articular (?efficacy)
– increased pain, joint swelling, and stiffness
– Not recommended for routine use
• Glucosamine & Chondroitin
– Controversial efficacy, not recommended to use
– Trial for 3 – 6 months
2.Urinary Incontinence
Urinary Incontinence
• Defined as the complaint of involuntary leakage of
urine
• 30% of older adults, women 2 x men
• Pelvic surgery, childbirth et al
• Reversible causes: DRIPP
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Delirium
Restricted mobility
Infection
Inflammation (atrophic vaginitis)
Impaction of feces
Polyuria (diabetes, caffeine intake, volume overload)
Pharmaceuticals
• Diuretics, alpha adrenergic agonists/antagonists, anticholinergics
Stress Incontinence
• Urethra and/or urethral sphincters
underactivity
• Pelvic surgery, childbirth, vaginal atrophy
– Coughing, laughing, sneezing
– Rx Surgery or pelvic muscle exercises (the best)
– Vaginally administered estrogen for atrophic
urethritis or vaginitis
Urge Incontinence
• Detrusor overactivity (gotta go!)
– Most common form
– Uninhibited bladder contractions
– Large volumes, nocturnal (sleep disturbances)
– Bladder retraining by voiding Q2h
• Anticholinergics (1st line) can be added (relaxes
bladder)
– Oxybutinin, Tolterodine (better tolerated)
– Urinary retention, confusion, constipation, dry mouth
– Orthostatic hypotension, tachycardia
Overflow Incontinence
• Dribbling after voiding
• Bladder cannot be emptied completely and large
volumes of residual urine remain after
micturition
• Bladder outlet obstruction or atonic bladder
– Prostatic hypertrophy, prostate cancer & urethral
strictures
– Spinal cord disease, autonomic neuropathy
(neurogenic bladder)
• Diabetes, alcoholism, B12 deficiency, Parkinson's
– Removal of obstruction (surgical)
– Intermittent catheterization 3 – 4 times daily
Overflow Incontinence
• Cholinomimetic bethanecol (25–50 mg three or
four times daily) is of uncertain effect but may be
trialed
– Muscle and abdominal cramping, hypersalivation,
diarrhea, and potentially life-threatening bradycardia
and bronchospasm
• α-adrenoceptor antagonists such as silodosin,
prazosin, terazosin, doxazosin, tamsulosin, and
alfuzosin may benefit this condition by relaxing
the bladder outflow tract and hence reducing
outflow resistance
• Less satisfactory alternatives include indwelling
urethral or suprapubic catheters
3.Benign Prostatic Hyperplasia
Males with BPH
• Alpha1 adrenergic blockers (rapid effect)
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Relaxes muscles of bladder neck, urethra
Decrease symptoms (nocturia)
First-line treatment for moderate to severe BPH
Terazosin, Doxazosin or Tamsulosin, Alfuzosin
30% to 80% improve in symptoms
Hepatically cleared, use lowest possible dose in liver
d/o
– 1st dose hypotension; give at bed time titrate up
slowly (q3-7 days)
Males with BPH
• 5 alpha reductase inhibitor (monotherpy)
– Block conversion of testosterone to
dihydrotestosterone
– Reduces prostate volume and decrease progression
– Finasteride, Dutasteride
– A minimum of 6 months is required to evaluate the
effectiveness of treatment
– Produce a mean 50% decrease in serum levels of PSA
– Combined with doxazosin if volume > 25 mL
– Adverse effects include decreased libido, erectile
dysfunction, and ejaculation disorders, gynecomastia
and breast tenderness
Combination Therapy
• α-adrenergic antagonist + 5α-reductase
inhibitor may be considered in symptomatic
patients at high risk of BPH complications
– Enlarged prostate of at least 30 g
– PSA of at least 1.5 ng/mL
• Relieve voiding symptoms
• Reduce the risk of developing BPH-related
complications
• Reduce the need for prostatectomy by 67%
Severe BPH
• Prostatectomy; transurethrally, open surgery
– For complications of BPH disease
• Recurrent urinary tract infection, urosepsis, urinary
incontinence, refractory urinary retention, chronic renal
failure, recurrent severe gross hematuria
– May lead to erectile dysfunction, retrograde
ejaculation, urinary incontinence, bleeding, or
urinary tract infection
• Drug treatment is used in inoperable patients
with severe disease