Topic VI: Bone & Joint Disorders Assessment

Topic VI: Bone & Joint Disorders Assessment

Calcium supplementation for people with the bone disease is associated with various benefits such as improving bone density, preventing osteoporosis, preventing fractures, and overall improvement of skeletal health (Li et al., 2018). However, calcium supplementation is also associated with an increased risk of malignancy and cardiovascular disease. Adverse events that are caused by calcium supplementation encompass myocardial infarction, kidney stones, colorectal neoplasms, and constipation (Li, et al., 2018).

The 59-year-old postmenopausal woman with a T-score of − 2.3 has a low bone density (osteopenia). The appropriate treatment for this patient is bisphosphonates such as ibandronic acid, zoledronic acid, alendronic acid, and risedronic acid. Bisphosphonates will prevent osteoporosis for this patient since she is having low bone density (Iqbal et al., 2019). The patient will also be advised to be physically active and take an osteopenia diet, rich in calcium and vitamin D.

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Risk factors for gout include high intake of meat, alcohol intake, sweetened beverages, and seafood as they increase uric acid levels (Ragab et al., 2017). Being overweight, medical conditions like high blood pressure, cardiovascular disease, diabetes, and taking medications such as thiazide diuretics used to treat high blood pressure increases the risk of gout. Gout is also common in men due to high uric acid levels. The risk factors for this patient include hypertension, being a male, alcohol intake, and hydrochlorothiazide (HCTZ) medication (Ragab et al., 2017).

Non-pharmacological treatment choices include taking a lot of fluids while limiting sweetened beverages; limiting/avoiding alcohol intake; reducing intake of meat, poultry, and fish; and maintaining a healthy weight (Claus & Saseen, 2018). Pharmacological treatment options for gout include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, Aleve, Indocin, and Celebrex; corticosteroids, and colchicine. The patient is a candidate for prophylactic therapy to prevent recurrent gout (Claus & Saseen, 2018).

References

Claus, L. W., & Saseen, J. J. (2018). Patient considerations in the management of gout and role of combination treatment with lesinurad. Patient-related outcome measures, 9, 231–238. https://doi.org/10.2147/PROM.S108868

Iqbal, S. M., Qamar, I., Zhi, C., Nida, A., & Aslam, H. M. (2019). Role of Bisphosphonate Therapy in Patients with Osteopenia: A Systemic Review. Cureus, 11(2), e4146. https://doi.org/10.7759/cureus.4146

Li, K., Wang, X. F., Li, D. Y., Chen, Y. C., Zhao, L. J., Liu, X. G., Guo, Y. F., Shen, J., Lin, X., Deng, J., Zhou, R., & Deng, H. W. (2018). The good, the bad, and the ugly of calcium supplementation: a review of calcium intake on human health. Clinical interventions in aging, 13, 2443–2452. https://doi.org/10.2147/CIA.S157523

Ragab, G., Elshahaly, M., & Bardin, T. (2017). Gout: An old disease in a new perspective – A review. Journal of advanced research, 8(5), 495–511. https://doi.org/10.1016/j.jare.2017.04.008

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Introduction

Osteoporosis 

Osteoporosis management requires a combination of adequate supplementation of Vitamin D and Calcium (through diet and supplements) as well as appropriate pharmacologic therapy such as bisphosphonates.

Supplementation requirements are patient specific due to diet (Table 56-4), risk factors (Table 56-1), age and gender. Not all supplements are created equally.  Be sure to read the labels and understand the various calcium salts in terms of elemental calcium per tablet (Table 56-5) and the factors that can affect absorption.  Patients on acid suppression therapy will benefit most from calcium citrate.

The indications for pharmacologic osteoporosis therapy vary dependent on many factors such as: gender, menopause, prevention or treatment, renal function, etc.  Be familiar with the appropriate indications (Table 56-6).

Osteoarthritis 

Osteoarthritis can occur with and without inflammation.  Determining the presence or absence of inflammation may affect your treatment decision.  (Think NSAID vs. Acetaminophen for example).

• Acetaminophen -First line therapy for mild to moderate osteoarthritis. Should be tried initially at an adequate dose and duration before considering an NSAID
• NSAIDs – Reasonable first-line therapy in patients with moderate-to-severe OA or Therapeutic failure of acetaminophen
  • Alternative to acetaminophen if clinical features of peripheral inflammation or severe pain are present
  • Reasonable adjunct therapy when APAP fails to provide an acceptable analgesic response.
  • If using an NSAID, consider gastrointestinal and cardiovascular risks:

Osteoarthritis is a chronic condition and treatment is not curative.  The goal is to treat symptoms and prevent disease progression.

Gout / Hyperurecemia

Diet and lifestyle modifications may be helpful to reducing the incidence of gout flares.

Certain medications can be causative to hyperuricemia and should be recognized. Certain medications are also uricosuric which may be helpful in reducing uric acid levels (fenofibrate, losartan).

The treatment of gout flares focuses on NSAIDs, colchicine and corticosteroids. Each treatment has different adverse effects and toxicities.  Understanding the adverse effect profile is essential to choosing the appropriate dosing.

Hyperuricemia can be present with or without gout flares.  Understand the appropriate indications for uric acid lowering therapy (ULT) such as: allopurinol, febuxostat, probenecid or pegloticase.

This module discusses various disorders of the bones and joints, including osteoporosis, osteoarthritis and gout.

Objectives

At the completion of this module the student will be able to:

Osteoporosis:

• discuss the utility of calcium and vitamin D supplementation.
• recommend non-pharmacologic therapy for osteoporosis.
• choose appropriate pharmacologic treatment (including supplementation) for a patient with osteopenia or osteoporosis.

Osteoarthritis:

• differentiate between the presentation and treatment of OA and RA.
• develop a treatment plan (nonpharmacological and pharmacological) for a patient with OA.
• modify a treatment plan that has not been successful.

Gout:

• discuss the dietary and lifestyle risk factors that may precipitate gout.
• create a treatment plan for a patient with an acute gout flare.
• evaluate the need for prophylactic treatment in a patient with an acute gout flare.
• recommend a treatment plan for a patient with hyperuricemia and gout.

 

Module VI	Discussions & Assignments
Discussion	Calcium and Vitamin D supplementation are essential to bone health and the management of osteopenia and osteoporosis.  In the past few years, information regarding the potential risks of too much calcium (such as cardiovascular disease and/or events) have been emerging. Using an article from a medical journal, evaluate and discuss the risks and benefits of calcium supplementation for a patient with a bone disease. What would you recommend for is a 59-year-old postmenopausal woman with a T-score of − 2.3. Her past medical history is unremarkable and she only takes a multivitamin with additional calcium and vitamin D. Her family history is remarkable for a mother who had osteoporosis and died of breast cancer and a father who has diabetes Gout is a common form of inflammatory arthritis that is very painful. It usually affects one joint at a time (often the big toe joint). Although there is no cure for gout, it can be effectively treated and managed with medication and self-management strategies A 45-year-old white man presents to your office complaining of left knee pain that started last night. He says that the pain started suddenly after dinner and was severe within a span of 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He has a history of hypertension for which he takes hydrochlorothiazide (HCTZ). He admits to consuming a great amount of wine last night with dinner Provide an evaluation of the patient including possible risk factors and treatment options, including non-pharmacologic interventions Would this patient be a candidate for prophylactic therapy?

 
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