Musculoskeletal Disorders Part 1 Part 2 and Medications for the Unit
Osteoarthritis
* Wear and tear, genetic component based on lifestyle (obesity, high impact job, lifting)
* Repetitive use contributes to it, articular cartilage damaged, thinner and thinner til it becomes bone on bone
* Loss of normal range joint motion, pain with weight bearing and use, secondary inflammation of surrounding tissue
* Aching with weight bearing, limited joint movement, in TMJ mastication and speaking are difficult
Treatment for Osteoarthritis
* Adaptive devices-cane
* Mild exercise and range of motion exercise
* TREAT PAIN-meds
* Glucosamine chondroitin supplements, NSAIDS, analgesics
* Glucosamine: sugar protein that helps body build cartilage
* Chondroitin: helps body maintain fluid and flexibility in joints
* These may interact with warfarin to increase bleeding
Rheumatoid Arthritis
* Autoimmune chronic systemic inflammatory disease-more common in women
* Pathophysiology: synovitis (inflammation of synovial fluid), abnormal tissue forming within the joint, cartilage erosion, can cause joint deformity if untreated
* Signs and Symptoms: inflammation, red, swollen, painful joints, joint stiffness and impaired movement, fatigue and low grade fever
Treatment for Rheumatoid Arthritis
* Delay progression, maintain joint function and relieve symptoms
* DRUGS: NSAIDS, glucocorticoids, methotrexate, infliximab, rituximab, anakinra
1. ASPIRIN: bleeding risk, ulcer risk, tinnitus, headache
2. Celecoxib: NSAID!!! Increased risk for MI or Stroke, stomach or intestine bleed
3. Ibuprofen-usual effects that you know
4. Diclofenac Sodium: Usually topical now, high first pass effect, anti-inflammatory, used for osteoarthritis, rheumatoid and ankylosing spondylitis
1. Very renal toxic and hepatotoxic
5. Ketorolac-the usual with this less than 5 days and other NSAID side effects
6. BIG ONE FOR RHEUMATOID: Glucocorticoids: prednisone- can cause hyperglycemia and weight gain, nervousness and restlessness, increased risk for infection
7. DMARDS
1. Methotrexate: First line treatment for Rheumatoid: evaluate renal and liver function
2. Bone marrow suppression so lower blood cells and increased infection risk
8. Infliximab-immunomodulator, can cause severe infections and lower neutrophils and can cause thrombocytopenia
9. Adalimumab: can cause active infection
Juvenile Rheumatoid Arthritis
* More acute onset than adult
* Enlarged lymph nodes, liver, and eyes
GOUT
* Results from deposits of uric crystals in the joint causing inflammation
* CAUSED FROM PURINES IN DIET or inadequate renal excretion
* Treated by reducing purine rich foods spinach, shellfish and mushrooms, and alcohol
* USE OF NSAIDS BEFORE BLOOD TEST CAUSES FALSE NEGATIVE
DRUG THERAPY FOR GOUT
Short term:
* NSAIDS-first line
* INDOMETHACIN
* COLCHICINE
Long term to lower blood levels of uric acid
* Allopurinol
* Febuxostat
* Probenecid
* Indomethacin: NSAID (increases MI or stroke)-acute gout
* Colchicine: only for people intolerant to safer agents, acute gout
* Allopurinol: Inhibits uric acid formation (febuxostat), allows joint function to improve, reverses hyperuricemia and stops nephropathy from deposition of urate crystals in kidney
* Initial therapy may cause acute gout attack, so start with NSAID and this
* Probenecid:Increases rate of uric acid excretion, treats chronic gout, eat with meals, inhibits reabsorption of uric acid can interact with aspirin
* Glucocorticoids for people who cannot use NSAIDS (usual side effects)
Ankylosing Spondylitis
* Chronic, progressive, inflammatory conditions, effects lots of back places, thought to be autoimmune (more in men 20-40 yrs)
* CAUSES KYPHOSIS, osteoporosis common
* Causes lower back pain, spine more rigid and inflammation of eye happens too
Bone Disorders
Osteoporosis
* Decrease in bone mass and density causes breakdown
* In women, overwork of osteoclasts, Age 50+, decreased calcium intake and sex hormones, can also be a secondary disorder
* Bone resorption exceeds formation, becomes porous lose compact bone can cause compression fractures of vertebrae, wrist, or hip, can lead to kyphosis and scoliosis
* Predisposing factors: excess corticosteroids or PTH, post menopausal higher risk, deficits of calcium, vitamin D, smoking, smaller bone structure
Treatment of Osteoporosis
* Bisphosphonates, Calcitonin, Raloxifene or tamoxifen
* Bisphosphonates-slow activity of osteoclasts-alendronate
* Calcitonin-opposes action of PTH
* raloxifene
* Tamoxifen-effects resemble estrogen reduces bone resorption and turnover
* Alendronate: patient must sit upright for 30 minutes, do not take with food, increases bone mineral density
* Raloxifene: Estrogen effects without cancer risk, can cause DVT, pulmonary embolism, stroke, IS CATEGORY X and teratogenic
Rickets
* Results from Vitamin D and phosphate deficit from the diet or lack of sun
* Children: can lead to weak bones and other skeletal deformities or compression fractures
Paget Disease
* Change in actual tissue, bone replaced by fibrous tissue, can lead to compression fractures and kyphosis, increased pressure in skull leading to headaches
Osteomyelitis
* Bone infection from bacteria, local inflammation, bone pain and treated with antibiotics or surgery
Muscular Dystrophy
* Group of autosomal recessive disorders-degeneration of skeletal muscle of time
* SIGNS AND SYMPTOMS: early motor weakness, waddling gait, difficulty climbing stairs, tendon reflexes reduced, cardiomyopathy occurs commonly
* DIAGNOSTIC TESTS: electromyography, muscle biopsy, blood tests
* No curative treatment, use supportive appliances and physiotherapy and occupational therapy to maximize function and adaptation
Fibromyalgia
* Group of disorders characterized by pain and stiffness
* Affects muscles and surrounding soft tissues
* Unknown cause really
* Signs and symptoms: aching pain, DEPRESSION
* Treatment: stress avoidance and reduction, regular morning exercise, antidepressants, NSAIDS, pregabalin-treats neuro pain, could be abused and do not use wit other CNS depressants
Muscle Relaxant Drugs
* Drugs for spasm and drugs for spasticity
* Spasm: sudden involuntary contraction of one of more muscles, sudden, sharp and may see lump
* Spasticity: increased muscle tone, increased reflexes, pain, decreased function and involuntary reflexes
Spasticity: movement disorders of CNS
* MS, cerebral palsy, spinal cord injury
* Heightened muscle tone, spasm, and loss of dexterity
Drugs for spasticity
1. Baclofen: suppresses hyperactive reflexes, mimics GABA, used for MS, spinal cord injury and cerebral palsy, not for spasticity for CVA: no antidote for overdose, CNS depressant, increased drowsiness, dizzy, fatigue and weakness, do not use alcohol or other CNS depressants, can cause Nausea and vomiting or urinary retention
1. Intrathecal route, abrupt discontinuation causes high fever, rebound spasticity, rhabdo, or death
2. Dantrolene
1. Acts directly on skeletal muscle, makes muscle less able to contract, used for spasticity, cerebral palsy and spinal cord injury
2. Treats malignant hyperthermia
3. Can be hepatotoxic!!
Muscle Spasm and Treatment
* Involuntary contraction of muscle or group of muscles
* Painful
* Causes: hypocalcemia, pain syndromes, trauma,
* Treatment: hot and cold, physical therapy, immobilization of affected muscles
* NSAIDS, muscle relaxers
* Hepatoxicity common with centrally acting muscle relaxants, relieve muscle spasm, sort of spastic, have dependence
* Cyclobenzaprine: muscle relaxer can cause anticholinergic effects and serotonin syndrome if combined with SSRIS
* Diazepam: benzo has dependence
Med list for new unit
Ondansetron: 2nd generation antipsychotic used for nausea in chemotherapy and for manic moods; medicated before chemo treatment
Cyclophosphamide: cytotoxic medication alkylating medication; kills cells non stage specific
Cisplatin: cross links DNA and is a platinum compounds
Methotrexate: antimetabolite S phase specific used for disrupting DNA synthesis; first line drug for rheumatoid arthritis; monitor liver and kidneys and do not give to alcoholics or people with liver disease it also suppresses the bone marrow
Fluorouracil: pyrimidine analog S phase specific, DNA synthesis and RNA synthesis kills dividing cells only
VIncristine: Mitotic inhibitors-stops mitosis in metaphase (keeps from dividing)
Tamoxifen: blocks estrogen receptors prevents breast cancer but has adverse effects like hot flashes, fluid retention, vaginal discharge, and teratogenic
Leuprolide: inhibits gonadotropin release and suppresses ovarian and testicular steroidogenesis, may experience hot flashes or have bone pain
Aspirin: nsaid that is a bleeding risk due to decreased platelet aggregation, risk for stomach ulcer formation, tinnitus and headache, treats rheumatoid arthritis,
Indomethacin: NSAID used for moderate to severe gout, increases MI or stroke without risk factors, GI, and bleeding risk, first choice for gout, for acute gout!
Ibuprofen: An NSAID of choice for RA, well tolerated, mild to moderate pain, increased risk MI or stroke
Naproxen: NSAID used to treat pain and inflammation used for Gout and RA
Celecoxib: treats pain and inflammation for Arthritis and spondylitis, increased risk for MI or stroke without risk factors
Diclofenac: High first pass effect and protein bound, typically topic, used in osteoarthritis, RA, and ankylosing spondylitis, risk for liver injury and renal impairment
Ketorolac: very powerful equivalent to opioids, moderate to severe pain, only 5 days due to increase risk of thrombotic events, renal failure, bleeding, and ulcers,
Etanercept: DMARD-suppresses immune function, serious infection risk, moderate to severe RA, liver injury
Infliximab: immunomodulator, RA and chrons, hepatic dysfunction, neutropenia (serious infections), thrombocytopenia
Adalimumab: RA, psoriatic arthritis, chrons and ulcerative colitis, infection risk
Allopurinol: inhibits the uric acid formation in chronic gout (maintenance med), joint function improves and decreases risk of nephropathy from the crystals, initial therapy may illicit gout attack, May have Gi or cataracts
Probenecid: chronic gout med, increases uric acid excretion and inhibits the resorption, take with food and a lot of liquid, and add indomethacin for relief, interacts with aspirin
Febuxostat: inhibits uric acid formation like allopurinol, careful of hepatic and renal function, for acute gout, may because bradycardia, leukopenia and neutropenia,
Prednisone: used in acute gout in NSAIDs are intolerable, also used for RA
Alendronate: slows activity of osteoclasts, do not take with food and have patient sit upright for 30 minutes after it is taken, used for osteoporosis
Raloxifene: can treat osteoporosis, used in postmenopausal women, estrogen like effects without the cancer risks, is teratogenic and risks for DVT, PE, stroke
Lyrica-pregabalin, treats fibromyalgia, good for neuropathic pain, do not use with CNS depressants, angioedema or rhabdomyolysis