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WELL Duquesne University Mylan School of Pharmacy

aware

UPDATE from the Center for Pharmacy Care

September-October 2004

Osteoarthritis–A Pain in the Joint!

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rthritis, defined as inflammation of a joint, is not just one disease, but actually has more than 100 forms. The Centers for Disease Control and Prevention (CDC) estimates that by the year 2020, more than 60 million people will have arthritis. The most common form of arthritis is osteoarthritis. Also called degenerative joint disease, osteoarthritis affects nearly 21 million people in the U.S. and is the NUMBER ONE cause of disability in America. Besides osteoarthritis, other common forms of “arthritis” are rheumatoid arthritis and gout. Arthritis is a common symptom in conditions such as lupus erythematous, fibromyalgia and Lyme disease. Because osteoarthritis is the most common form of arthritis, focus has been placed on its prevention and treatment. This will hopefully reduce the growing number of patients disabled by the disease.

What is Osteoarthritis? Osteoarthritis (OA) is caused by the breakdown of joint cartilage. Normally, cartilage helps to cushion the ends of bones to prevent movement of bone against bone. As cartilage deteriorates, the bones rub together causing pain and stiffness. OA typically develops in only one joint, but when fingers are involved, multiple joints may be affected. OA usually affects fingers, spine (neck or lower back), and weight-bearing joints (hips, knees, and feet).

It is uncommon for OA to affect the jaw, shoulder, elbows, wrists or ankles unless you have had a previous injury or unusual stress placed on the joint. Pain is the primary symptom of OA and can vary from being mild to becoming debilitating. Inflammation is usually only a minor component of osteoarthritis. Treatment focuses on decreasing pain and increasing joint flexibility.

Signs and Symptoms of Osteoarthritis • Pain in a joint during or after use, or after a period of inactivity

• Swelling and stiffness in a joint, particularly after using it

• Discomfort in a joint before or during a change in the weather

• Bony lumps on the middle or end joints of your fingers or the base of your thumb • Loss of joint flexibility

Upcoming Events Mark Your Calendar Center for Pharmacy Care – Wellness Mondays The Center offers the following complimentary screenings on Mondays by appointment: Bone Density, Body Composition Analysis, Facial Skin Analysis, Cholesterol Screening Please call 412-396-5874 for an appointment.

All events will be held in the Center for Pharmacy Care, Room 320 Bayer Learning Center, unless otherwise noted.

Please call x5874 to RSVP for screenings and lunchtime lectures.

SEPTEMBER – Focus on Fitness • September 1, 2004, 11:30 a.m.-12:30 p.m. Blood Pressure Check-Up • September 15, 2004, 11:30 a.m.-12:30 p.m. Blood Pressure Check-Up • September 13, 20 & 27, 2004, 9:00 a.m.-1:00 p.m. Center for Pharmacy Care Wellness Mondays

OCTOBER – Talk About Prescriptions Month • October 6, 13 & 20, 2004, 11:00 a.m.-1:00 p.m. Blood Pressure Screening “Ask the Pharmacist” – Feel free to bring your prescriptions and your questions to this complimentary consultation Location: Union, 3rd Floor Concourse • October 4, 11 & 18, 2004, 9:00 a.m.-1:00 p.m. Center for Pharmacy Care Wellness Mondays Groups forming now for the following: • Tobacco Cessation Program • Walking Club For more information, please call x5874

www.duq.edu


Osteoarthritis–A Pain in the Joint! Who is at risk for developing Pharmacologic Therapy Drug selection is based on disease severity. osteoarthritis? People who are 45 years of age or older, females, and those who are obese are at greater risk for the development of osteoarthritis. Other risk factors include certain hereditary conditions associated with defective cartilage or malformed joints, joint injury due to physical activity or sports, or other diseases that may change the normal structure and function of cartilage.

How is osteoarthritis diagnosed? A physician can make a diagnosis of osteoarthritis based on physical examination and a history of symptoms. The diagnosis can be confirmed through the use of various radiologic or X-ray studies. Bone spurs, damaged cartilage or loss of joint space can be identified using these techniques. There are no useful blood tests for diagnosing osteoarthritis.

What is the treatment for osteoarthritis? Although there is no cure for osteoarthritis, a variety of treatments can help reduce pain and maintain joint mobility. The current management of OA incorporates non-pharmacologic approaches combined with prescription and over-the-counter (OTC) drugs and alternative remedies.

The American College of Rheumatology still considers acetaminophen (Tylenol®, etc.) the drug of choice for initial management of osteoarthritis. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used if there is insufficient relief with acetaminophen. These are available as prescription and OTC products. Elderly patients and those with a history of ulcer disease or gastrointestinal bleeding may use the newer COX-2 inhibitors (Vioxx®, Celebrex®, Bextra®) to reduce the risk of these complications. As pain increases, drugs such as tramadol (Ultram®) and narcotic analgesics may eventually be required. Intra-articular (directly into the joint) injections of drugs such as Synvisc® or corticosteroids like Depo-Medrol® can provide significant relief.

Alternative Treatments There are various alternative therapies that may be effective in osteoarthritis. One of the most popular is a combination of the natural substances glucosamine and chondroitin. Glucosamine is thought to be important for cartilage formation and repair, while chondroitin gives cartilage elasticity. Several studies have shown that glucosamine and chondroitin

may be effective for relieving mild to moderate osteoarthritis pain. Both of these substances are available as dietary supplements. In clinical trials, the usual daily doses of glucosamine and chondroitin have been 1500 mg and 1200 mg respectively. The most common side effects are increased intestinal gas and softened stools. Normal doses do not appear to affect blood sugar levels in Type 2 diabetes. Other less common alternative treatments include acupuncture, homeopathy, wearing copper jewelry, magnets, etc. There is limited research to support the use of these alternative or complementary therapies in OA. Patients should consult their physicians before using any of these treatments. Osteoarthritis is a debilitating disease that affects millions of Americans. With proper management, many patients can reduce their pain and hopefully lead a normal, active life. For more information on pharmacologic and non-pharmacologic treatment of osteoarthritis, visit the online version of Well Aware.

www.pharmacy.duq.edu/

Non-Pharmacologic Measures in Osteoarthritis There are a variety of self-care techniques that can be used to minimize the pain and stiffness associated with osteoarthritis. Exercise, diet, application of heat and/or cold, etc. are invaluable aids for symptomatic relief in osteoarthritis. They are an integral part of the management of this disorder and should never be underestimated.

Newsletter Contributors John G. Lech, Pharm.D. Christine O’Neil, Pharm.D., B.C.P.S. Nicole E. Andria, Pharm.D. Candidate Lauren N. Machajewski, Pharm.D. Candidate

Additional information regarding osteoarthritis may be obtained by visiting the following Web sites: • www.arthritis.org

• www.mayoclinic.com

• www.niams.nih.gov

• www.rheumatology.org

A publication of the Duquesne University Mylan School of Pharmacy Pharmacy Care Awareness Program (PCAP) & Pharmaceutical Information Center (PIC) Additional information on any of the topics discussed may be obtained from the Pharmaceutical Information Center by calling 412-396-4600 or sending an e-mail to pic@duq.edu. Questions about screenings or programs: Christine O’Neil, Pharm.D, B.C.P.S. 412-396-6417

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Osteoarthritis–Treatments Non-Pharmacologic Treatment Options for Osteoarthritis • EXERCISE – regular exercise can help relieve some of the symptoms of osteoarthritis. Exercises that help to strengthen muscles and improve range of motion, such as walking, bike riding, or swimming, are excellent ways to reduce joint pain and stiffness while increasing flexibility. • DIET – eating a balanced diet consisting of fruits, vegetables, and whole grains can help you control your weight and maintain your overall health. Maintaining an adequate weight is especially important because excess weight can put stress on areas where osteoarthritis pain is commonly felt such as the back, hips, knees, and feet.

• APPLY HEAT – taking a 15-minute hot shower or bath, or applying a heating pad to affected areas can help ease pain, relax tense, painful muscles, and increase blood flow. Applying heat is especially helpful before exercising. Heat is not helpful in reducing inflammation. • APPLY COLD – applying cold for occasional flare-ups can be useful for quick relief of arthritis pain. Cold has a numbing effect and can decrease muscle spasms.

Pharmacologic Treatment Options for Osteoarthritis* ORAL • Acetaminophen • COX-2 inhibitors (Celebrex®, Vioxx®, etc.) • Nonselective NSAID plus misoprostol (Cytotec®) or a proton pump inhibitor (Prilosec®, Prevacid®, etc.) • Tramadol (Ultram®)

Pharmacologic Therapy in Osteoarthritis TREATMENT

HOW IT WORKS

Topical pain relievers (Aspercreme®, Icy Hot®, Capzasin®)

Alleviates pain at the site of application

Local irritation to skin

Acetaminophen (Tylenol®)

Relieves pain but not inflammation

Risk of liver damage increases if you exceed 4 grams per day or consume more than 3 alcoholic drinks a day

NSAIDs – OTC and prescription products (Advil®, Aleve®, Voltaren®, Clinoril®, etc.)

Reduces inflammation and pain

High dose or long-term use can cause GI bleeding, gastric ulcers, hypertension, swelling of the ankles, kidney damage, etc.

COX-2 inhibitors (Vioxx®, Celebrex®, Bextra®)

Reduces inflammation and pain

Swelling of the ankles, hypertension, kidney damage, etc. (gastric ulceration and bleeding can occur, but are less common than with standard NSAIDs)

Tramadol (Ultram®)

Relieves pain but not inflammation

Drowsiness, dizziness, headache, nausea, vomiting, sweating, itching, etc.

Opioid analgesics (Tylenol #3®, Vicodin®, Percocet®, etc.)

Relieves pain but not inflammation (used for severe pain)

Drowsiness, dizziness, nausea and vomiting

Intra-articular injections (Synvisc®, Hyalgan®, DepoMedrol®)

Synvisc®, Hyalgan® provide lubrication; Depo-Medrol® reduces inflammation and pain

Pain and swelling at the site of injection

• Narcotic analgesics (Vicodin®, Percocet®, etc.)

INTRA-ARTICULAR INJECTIONS • Glucocorticoids (Depo-Medrol®, Kenalog®, etc.) • Hyaluronic acid derivatives (Synvisc®, Hyalgan®, etc.)

TOPICAL AGENTS • Capsaicin (Capzasin-P®, Zostrix®, etc.) • Methylsalicylate (Icy Hot®, Ben-Gay®, etc.)

*Adapted from the American College of Rheumatology Guidelines for Treatment of Osteoarthritis, 2000

SIDE EFFECTS


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