Osteoarthritis & Gouty Arthritis

OSTEOARTHRITIS
& GOUTY ARTHRITIS
Maria Carmela L. Domocmat, RN, MSN
Instructor, School of Nursing Northern Luzon Adventist College

Overview
2

Part 1: Degenerative & Metabolic bone disorders:
OA
Gout and gouty arthritis
Osteoporosis
Paget’s dse
Osteomalacia
Part 2: Bone infections
Part 3: Muscular disorders
Part 4: Disorders of the hand
Part 5: Spinal column deformities
Part 6 : Disorders of foot
Part 7: Sports Injuries
Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Osteoarthritis
associated with the
aging process and can
affect any joint.
The cartilage of the
affected joint is
gradually worn down,
eventually causing
bone to rub against
bone.
Bony spurs develop on
the unprotected bones,
causing pain and
inflammation. Maria Carmela L. Domocmat, RN, MSN

What’s the difference between RA
and OA?


Osteoarthritis is a deterioration of cartilage and
overgrowth of bone often due to "wear and tear."

Rheumatoid arthritis is the inflammation of a joint's
connective tissues, such as the synovial membranes,
which leads to the destruction of the joint's
cartilage.


Osteoarthritis
Known as the “wear-and-tear” kind of arthritis
a chronic condition characterized by the breakdown
of the joint’s cartilage.
Cartilage is the part of the joint that cushions the ends
of the bones and allows easy movement of joints. The
breakdown of cartilage causes the bones to rub
against each other, causing stiffness, pain and loss of
movement in the joint.


Osteoarthritis
AKA
degenerative joint disease,
ostoarthrosis,
hypertrophic arthritis
degenerative arthritis.


Stages of osteoarthritis
Cartilage loses elasticity and is more easily damaged
by injury or use.
Wear of cartilage causes changes to underlying bone.
The bone thickens and cysts may occur under the
cartilage. Bony growths, called spurs or osteophytes,
develop near the end of the bone at the affected
joint.


Stages of osteoarthritis
Bits of bone or cartilage float loosely in the joint
space.
The joint lining, or the synovium, becomes inflamed
due to cartilage breakdown causing cytokines
(inflammation proteins) and enzymes that damage
cartilage further.


The main problem in
knee OA is
degeneration of
the articular cartilage.
Articular cartilage is the
smooth lining that covers
the ends of bones where
they meet to form the
joint. The cartilage gives
the knee joint freedom
of movement by
decreasing friction.


The articular cartilage
is kept slippery by
joint fluid made by the
joint lining (the synovial
membrane). The fluid,
called synovial fluid, is
contained in a soft
tissue enclosure around
synovial joints called
the joint capsule.

An important substance
present in articular
cartilage and synovial
fluid is called hyaluronic
acid. Hyaluronic acid
helps joints collect and
hold water, improving
lubrication and reducing
friction. It also acts by
allowing cells to move
and work within the
joint.

When the articular
cartilage degenerates,
or wears away, the
bone underneath is
uncovered and rubs
against bone.
Small outgrowths
called bone spurs,
or osteophytes, may
form in the joint.


Changes in the cartilage and bones of the joint can
lead to pain, stiffness and use limitations.
Deterioration of cartilage can:
Affect the shape and makeup of the joint so it doesn’t
function smoothly. - limp when walk or have trouble going
up and down stairs.
Cause fragments of bone and cartilage to float in joint fluid
causing irritation and pain.
Cause bony spurs, called osteophytes, to develop near the ends
of bones
Mean the joint fluid doesn’t have enough hyaluronan, which
affects the joint’s ability to absorb shock.

Causes and Risk factors
There is no single known cause of osteoarthritis
several risk factors
Age
Obesity
Injury or Overuse
Genetics or Heredity
Muscle Weakness
Other Diseases and Types of Arthritis


Long-Term Complications


Management


Management
Weight reduction
Use of splinting devices to support joints
Occupational and physical therapy
Pharmacologic management


Paraffin wax


TENS


Physical Therapy
There is no treatment to
stop the erosion of
cartilage in the joints, but
there are ways to improve
joint function. One of these
is physical therapy to
increase flexibility and
strengthen the muscles
around the affected joints.
The therapist may also
apply hot or cold
therapies such as
compresses to relieve
pain.


Supportive Devices
Supportive devices, such
as finger splints or knee
braces, can reduce stress
on the joints and ease
pain. If walking is difficult,
canes, crutches, or walkers
may be helpful. People
with osteoarthritis of the
spine may benefit from
switching to a firmer
mattress and wearing a
back brace or neck collar.


lumbosacral corsets


Osteoarthritis and Weight
If you're overweight, one
of the most effective ways
to relieve pain in the knee
or hip joints is to shed a
few pounds.
Even modest weight loss
has been shown to reduce
symptoms of osteoarthritis
by easing the strain on
weight-bearing joints.
Losing weight not only cuts
down on pain, but may
also reduce long-term joint
damage.

Osteoarthritis and Exercise
People with osteoarthritis may
avoid exercise out of concern
that it will cause pain.
But low-impact activities
such as swimming, walking,
or bicycling can improve
mobility and increase
strength.
Training with light weights can
help by strengthening the
muscles that surround your
joints. For example,
strengthening the quadriceps
can reduce pain in the knees.


Let’s Exercise
http://www.medicinenet.com/rheumatoid_arthritis_
exercises_slideshow/article.htm


Treatment
Acetaminophen (Tylenol)
Topical analgesics OTC
Topical salicylates (Aspercreme)
Capsaicin
Nonsteroidal anti-inflammatory drugs (NSAIDs) or COX-2
medications
Tramadol
Narcotic pain relievers
Intra-articular steroids to decrease inflammation
Hyaluronans: Hyaluronate (Hyalgan) ad hylan GF 20 (Synvisc)
Cyclobenzapine HCl (Flexeril)
glucosamine and chondroitin sulfate


Acetaminophen
Tylenol, Anacin-3, Panadal, Phenaphen, Valadol,
and others)
for mild to moderate osteoarthritis.
usually the first choice


Nonsteroidal anti-inflammatory drugs
(NSAIDs)
for moderate to severe arthritic pain.
OTC NSAIDs
Prescription NSAIDs include


Drugs for Prevention NSAID-Induced
Ulcers
If NSAID-induced ulcers are identified switch to
alternative pain relievers.


Topical NSAIDs

$63.07


Capsaicin (Zostrix)
is an ointment prepared from the active ingredient
in hot chili peppers that has been helpful for
relieving painful areas in other disorders.


SALONPAS PAIN PATCH WITH CAPSAICIN


Tramadol (Ultram)
is a pain reliever that has some properties that are
similar to narcotics.
not as addictive, however, and may be an
alternative for patients who do not respond to
NSAIDs or less potent agents.


Narcotic pain relievers
oxycodone, oxymorphone, or morphine
may be necessary for severe pain that does not
respond to less potent pain relievers.


http://differncebetween.infoloommedia.netdna-cdn.com/wp-
content/uploads/2009/11/oxycodone.png

Supplements
Overall studies suggest no
benefits of glucosamine
and chondroitin –
supplements available at
pharmacies and health
food stores touted for
relieving pain and
stiffness for people with
osteoarthritis.
Check with doctor before
using chondroitin,
especially if taking blood-
thinners.


Intra-articular steroids

Generic Name Brand Name
betamethasone Celestone
methylprednisolone Depo-Medrol
triamcinolone Kenalog


Intra-articular steroids


Surgical treatment


Preventing Osteoarthritis
The most important thing you can
do to ward off osteoarthritis is
keep your weight in check.
Over the years, extra weight puts
stress on the joints and may even
alter the normal joint structure.
Preventing injuries is also
important.
Take precautions to avoid
repetitive motion injuries on the
job.
If you play a sport, use proper
equipment and observe safety
guidelines.


Gouty arthritis
is a disease characterized by an abnormal
metabolism of uric acid, resulting in an excess of
uric acid in the tissues and blood causing
inflammation
People with gout either produce too much uric acid,
or more commonly, their bodies have a problem in
removing it.


Gouty arthritis
AKA
Gout
The disease of kings
The king of diseases


Gouty arthritis
2 major types
Primary
Secondary


Primary Gouty arthritis
Inherited X-lined trait
Caused by several inborn errors of purine
metabolism
Uric acid- is the end-product of purine metabolism;
excreted in urine
Production of uric acid exceeds the excretion
capability of kidneys
Sodium urate is deposited in the synovium and other
tissues which results in inflammation
Males, 30’s and 40’s

Secondary Gouty arthritis
Affects all ages
Hyperuricemia : Excessive uric acid in blood caused by
another disease
Renal insufficiency
Diuretic therapy
Multiple myeloma
Carcinomas
Causes:
decreased normal excretion of uric acid and other waste
products
Increased production of uric acid


Four Stages Of Gouty Arthritis
Asymptomatic Hyperuricemia

Acute Gout / Acute Gouty Arthritis

Interval / Intercritical

Chronic Tophaceous Gout


(1) Asymptomatic Hyperuricemia:
Asypmptomatic but with elevated blood uric acid
levels

Serum uric acid level (mg/dl) Incidence of gout

>9.0 7.0-8.9

7.0-8.9 0.5-0.37

<7.0 0.1%


(2) Acute Gout / Acute Gouty Arthritis
First “attack” of GA
hyperuricemia has caused deposits of uric acid crystals
in joint spaces, leading to gouty attacks.
Excruciating pain and inflammation of one or more
joints – esp metatarsophalangeal joints of the great toe
(podagra)
Increased ESR, WBC


Note: Excessive alcohol and fad “starvation” diets can
cause acute gouty attacks


http://cdn.nursingcrib.com/wp-content/uploads/gouty-arthritis.jpg


http://img.medscape.com/slide/migrated/e
ditorial/cmecircle/2004/3689/images/cohen
/slide019.gif


(3) Interval / Intercritical
the periods between acute gouty attacks – may be
months or years after the 1st attack
Asymptomatic period
No abnormality in joints
(4) Chronic Tophaceous Gout:
the disease has caused permanent damage
Deposits or urate crytals under skin and within major
organs (i.e., urate kidney stone formation)


Tophi
Tophi – deposits of sodium urate crystals
May occur anywhere; common in outer ear

http://www.hopkins-arthritis.org/images/gout_fig7.gif


http://www.cdaarthritis.com/images_slides/40_gout_b_toe1_360.jpg

http://img.medsca
pe.com/slide/migr
ated/editorial/cme
circle/2004/3689/i
mages/cohen/slid
e019.gif


http://img.medscape.com/slide/migr
ated/editorial/cmecircle/2004/3689/i
mages/cohen/slide019.gif


http://msnbcmedia1.msn.com/i/ms
nbc/Components/Interactives/Healt
h/MiscHealth/GOUT.gif


http://img.medscape.com/slide/migrated/editorial/cmecircle/2004/3689/images/cohen/slide019.gif


Dx tests
Synovial fluid analysis (shows uric acid crystals)
Uric acid - blood
Joint x-rays (may be normal)
Synovial biopsy
Uric acid - urine


Management
Drug therapy
Diet therapy


Management
Drug therapy
acute gouty arthritis – inflammation subsides
spontaneously within 3 to 5 days
But if cannot tolerate pain
Colchicine (Colsalide, Novocolchicine) and NSAIDs
Taken for 4-7 days
(NSAIDs) -Indomethacin (Indocin), ibuprofen (Advil), and
naproxen (Aleve), celecoxib (Celebrex)
painkillers such as codeine, hydrocodone,
and oxycodone
Corticosteroids

Management
Drug therapy: Chronic or repeated acute episodes
Uricosuric drug
1. Allopurinol (Zyloprim)
2. Probenecid (Benemid, Benuryl)
Combination drug
Probenecid and Colchicine (ColBenemid)


Management
Uricosuric drug – promotes excretion of excess uric acid
Promote uric acid excretion or reduce its production
1. Allopurinol (Zyloprim)
A xanthine oxidase inhibitor – prevents conversion of
xanthine to uric acid
2. Probenecid (Benemid, Benuryl)
drink at least 2 liters of fluid a day while taking this
medication (to help prevent uric acid kidney stones from
forming).


Management

Combination drug
Probenecid and Colchicine (ColBenemid)
Note: avoid aspirin – it inactivates the drug
Monitor serum uric acid level


Febuxostat (Uloric)
first new medication developed specifically for the
control of gout in over 40 years.
Decreases formation of uric acid by the body and is a
very reliable way to lower the blood uric acid level.
can be used in patients with mild to moderate kidney
impairment.
should not be taken with 6-mercaptopurine (6-MP), or
azathioprine.
http://www.emedicinehealth.com/gout/page7_em.htm#Medications


Management: Diet therapy
Controversial
Strict low-purine diet
Limit protein foods
Avoid alcohol and fad “starvation” diets


Starvation Diet
A potentially dangerous fad diet that provides 300–700 kcal/day,
which must be supplemented with high quality protein; given the risk
of death through cardiac arrhythmias, starvation diets should be
limited in duration
Adverse effects
Orthostatic hypotension due to loss of sodium,
xeroderma
decreased norepinephrine secretion,
fatigue,
hypothermia,
cold intolerance,
xeroderma,
hair loss,
dysmenorrhoea
Segen's Medical Dictionary. © 2011 Farlex, Inc. All rights reserved.


Fad diet
Any of a number of weight-reduction diets that
either eliminate one or more of the essential food
groups, or recommend consumption of one type of
food in excess at the expense of other foods; FDs
rarely follow modern principles for losing weight.

McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill
Companies, Inc.


Avoid legumes (dried beans
alcohol and peas)
anchovies Gravies
sardines mushrooms
oils spinach
organ meat (liver, asparagus
kidney, and cauliflower
sweetbreads) baking or brewer's
yeast
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/


Limit meat
Avoid fatty foods such as salad dressings, ice
cream, and fried foods.
Eat enough carbohydrates.
If losing weight, lose it slowly. Quick weight loss
may cause uric acid kidney stones to form.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/


http://s1.hubimg.com/u/1184832_f496.jpg

Avoid all forms of aspirin and diuretics – may
precipitate attack
Excessive physical or emotional stress- can
exacerbate disease


Prevention of kidney stone formation

Increase fluid intake
To prevent stone formation
Dilute urine and prevent sediment formation
Alkaline ash diet
Citrus fruits, juices, milk and certain dairy products
Uric acid is more soluble in high pH urine – less likely
to form urinary stones


Complications
Chronic gouty arthritis
Kidney stones
Deposits in the kidneys, leading to chronic kidney
failure


Osteoarthritis & Gouty Arthritis

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