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
➢ Annual incidence of knee OA is highest between 55 and 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
SYMPTOMS

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
TAB. Amlodipine 2.5 mg 1-0-0

19. DAY ON EXAMINATION DRUGS DOSE FREQUENCY
3 T- 98.40F TAB. Diclofenac
TAB. Ranitidine
TAB. BC/Cal
TAB. Losartan
TAB. 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- 98.40F
PR- 76/mt
RR- 20/mt
BP- 140/80 mmHg
SpO2- 96%
Tenderness +
CST

20. DAY ON EXAMINATION DRUGS DOSE FREQUENCY
5 T- 98.40F
PR- 84/mt
RR- 22/mt
BP- 150/90 mmHg
SpO2- 95%
CST
6 T- 98.40F
PR- 86/mt
RR- 20/mt
BP- 120/80 mmHg
SpO2- 96%
CST

21. DAY ON EXAMINATION DRUGS DOSE FREQUENCY
7 T- 98.20F
PR- 88/mt
RR- 22/mt
BP- 120/70 mmHg
SpO2- 96%
TAB. Paracetamol
TAB. Calcium
TAB. Losartan
500 mg
50 mg
2.5 mg
1-0-1
1-0-1
1-0-1

22. INTERVENTION
➢ Total Knee Arthroplasty should have been done in this 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
TAB. Amlodipine 2.5 mg 1-0-0

24. Monitoring parameters
DRUGS BRAND NAME MONITORING
PARAMETERS
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
1. Osteoarthritis - OrthoInfo - AAOS (2022). Available at:
https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis/
2. OA Prevalence and Burden - Osteoarthritis Action Alliance (2022). Available
at: https://oaaction.unc.edu/oa-module/oa-prevalence-and-burden/
3. 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.
4. Osteoarthritis - Symptoms and causes (2022). Available at:
https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925

29. 5.Osteoarthritis: Symptoms, Causes and Treatment (2022). Available at:
https://my.clevelandclinic.org/health/diseases/5599-osteoarthritis
6.Morgan, K. and Ahlawat, R. (2021) "Ranitidine", StatPearls Publishing, p. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK532989/
7.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
8. Ranitidine Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing - WebMD
(2022). Available 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.

30. THANK YOU