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Arthritis: Pharm phacts & December 2014

Cain Eric Kirk Doctor of Pharmacy Candidate, 2015

Understanding : It is more than aches and

Arthritis affects more than 50 million known presentations are osteoarthritis prevent the reoccurrence of those acute Americans and is the most common (OA), (RA), gout, episodes, gone are the days of suffering reason for in the United and juvenile arthritis. in silence! States. In the U.S., over 44 million office visits In this newsletter, you will find Once considered an ailment of the and almost 1 million hospitalizations information pertinent to understanding elderly, we now know that arthritis is a occur each year due to arthritic and managing both osteoarthritis and complex family of musculoskeletal complications. As such, arthritis gout. For each, you will discover that disorders that encompasses over 100 contributes significantly to the growing eating right and along with different . More than two- burden on both the system medications when appropriate will thirds of those affected are less than 65 and economy in America. make life with arthritis years old. enjoyable…again! As of today, there are treatments While arthritis can take many forms, available to manage both the pain some of the most common and well- associated with arthritis flares and to

Inside This Issue: 2. Osteoarthritis: Diagnosis & Treatments 3. Gout & Hyperuricemia 12

Arthritis: OA & GOUT Drug therapies for OA:

Acetaminophen (Tylenol) – preferred treatment option for patients with OA who are just beginning therapy. This medication is available over-the-counter (OTC) and results in decreased pain and stiffness with minimum side effects. Unlike with other uses of this medication such as , it is recommended that acetaminophen be taken on a regular basis versus as needed. A typical regimen of acetaminophen for a patient with OA <65 years old would normally be 1,000 mg every 6 hours. Patients >65 years old or those who abuse alcohol should consult a Osteoarthritis: Diagnosis physician and limit daily use of and Treatments acetaminophen to <3,000 mg per day.

Alternatives to Acetaminophen Osteoarthritis (OA) is a slowly OA include those who have progressive disorder of the weight- experienced trauma to their at 1. NSAIDs – available as both OTC and prescription, these drugs are safe and bearing joints that results in some time, suffer from , have effective therapies for patients who deterioration or loss of joint , repetitive use of the joint through have attempted scheduled doses of pain, limited , either work or leisure activities, and acetaminophen and failed to show deformity, and disability of the joint. those who are genetically predisposed. benefit. Patients 65 and older or those with history of GI bleeds should be OA may affect only one or several Diagnosis is most commonly made on cautious when using this drug. joints throughout the body. The most a number of findings and laboratory Common examples include commonly affected joints are found in tests used by the physician or other , , Celebrex, and Nabumetone. the hands, feet, , and spine. healthcare practitioner to confirm OA. The first criteria for diagnosis is deep, 2. Topical Creams/Ointments – can be The predominant symptom of OA is localized pain in the joint. Additional used with oral therapies when deep, aching, localized pain affecting criteria include joint deformities found adequate relief of pain and stiffness is one or more of the joints mentioned not experienced. Examples include on physical exam or radiographic above. Additionally, patients suffering Icy Hot, Capzasin, and Bengay. findings. There are also several from OA may experience swelling, laboratory tests to exclude the 3. Intra-articular Injections – these redness, limited use, and cracking or injections are given by trained possibility of other causes of the pain, popping of the affected joints. Also physicians directly into the affected including rheumatoid arthritis (RA). or joint spaces. While typical of OA is that effective, they are usually reserved for improves with movement of the joint. The treatment of OA includes patients not experiencing relief with regimens to decrease joint pain and other therapies. Patients at risk for the development of 43

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stiffness, maintain mobility, and minutes a day, 5 days a week. preserve . Both lifestyle Isometric , which target small interventions and the use of drug muscle contractions without therapies are used in the management movement of the joint, can improve of OA. joint mobility and reduce pain. Hot or cold compresses can also reduce pain. For patients, is Gout: Presentation and recommended to decrease or alleviate There are a number of OTC and Treatment joint pain. These patients should use a prescription medications available to Patients with gout will most commonly balanced approach to weight loss reduce pain associated with OA. have complaints of abrupt pain, swelling, and . This often occurs in including both dietary changes and Topical creams and ointments, OTC only one joint, mainly of the large toe. exercise regimens. pain relievers such as Tylenol and However, progression can occur leading to Aleve, and prescription medications several other joints becoming inflamed and All patients with OA will benefit from such as Celebrex or injections painful. exercise regimens of a minimum of 30 into the joint space. (See left of page 2.) Drug therapy for gout includes both medications for the management of acute gout attacks as well as medications to prevent the reoccurrence of future gout attacks.

Therapies for the management of acute gout attacks include NSAIDs, corticosteroids, and Colchicine. Corticosteroids and colchicine are both available only by prescription from your physician. Colchicine can only be initiated if the time since the onset of the acute attack is <48 hours.

GOUT AND HYPERURICEMIA There are two classes of medications to Hyperuricemia is the underlying disorder most closely associated with gout. It is help prevent the reoccurrence of acute gout attacks. Examples of these drugs are defined as serum urate concentration >7 mg/dL in men and >6 mg/dL in women. allopurinol and probenecid, both of which While hyperuricemia commonly leads to the development of gout, many times it are available only by prescription from goes undetected, as the patient has no symptoms. Gout develops as urate reaches your physician. such high levels in the blood stream that the molecules begin to precipitate out of Patients with gout should also be aware the blood to form urate crystals. These crystals commonly collect in the small joints that diet heavily influences the of the feet and toes, and lead to the development of inflammation, pain, development and reoccurrence of attacks. tenderness, and immobility. Gout can also affect the joints of the , knees, Sufferers of gout should limit saturated fats wrists, fingers, and elbows. and purine-rich meats, alcohol, and should consume adequate amounts of water. Arthritis: OA & GOut December 2014 Gout Friendly Diet Pyramid

References:

Arthritis Facts [Internet]. Atlanta: Arthritis Foundation; c2014. Understanding Arthritis; 2014 [cited 2014 Dec 2]; [about 3 screens]. Available from: http://www.arthritis.org/arthritis-facts/understanding-arthritis.php.

Buys LM and Elliott ME. Osteoarthritis. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy: A pathophysiologic approach. 8th ed. New York: McGraw-Hill Medical; c2011. Chapter 101.

Ernst ME and Clark EC. Gout and hyperuricemia. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy: A pathophysiologic approach. 8th ed. New York: McGraw-Hill Medical; c2011. Chapter 102.

Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P. American College of 2012 recommendations for the use of non-pharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care and Res. 2012 April;64(4):465-74.

Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T, Pillinger MH, Merill J, Lee S, Prakash S, Kaldas M, Gogia M, Perez-Ruiz F, Taylor W, Liote F, Choi H, Singh JA, Dalbeth N, Kaplan S, Niyyar V, Jones D, Yarows SA, Roessler B, Kerr G, King C, Levy G, Furst DE, Edwards NL, Mandell B, Schumacher HR, Robbins M, Wenger N, Terkeltaub R. 2012 American College of Rheumatology guidelines for management of gout. Part #1: systematic nonpharmacological and pharmacological therapeutic approaches to hyperuricemia. Arthrit Care Res. 2012 Oct;64(10):1431-46.

Khanna D, Fitzgeral JD, Khanna PP, Bae S, Singh MK, Neogi T, Pillinger MH, Merill J, Lee S, Prakash S, Kaldas M, Gogia M, Perez-Ruiz F, Taylor W, Liote F, Choi H, Singh JA, Dalbeth N, Kaplan S, Niyyar V, Jones D, Yarows SA, Roessler B, Kerr G, King C, Levy G, Furst DE, Edwards NL, Mandell B, Schumacher HR, Robbins M, Wenger N, Terkeltaub R. American College of Rheumatology guidelines for management of gout. Part #2: therapy and anti-inflammatory prophylaxis of acute gouty arthritis. 2012 Oct;64(10):1447-61.