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Module 4_ Musculoskeletal

Maryn Moreni・33 minutes read

The lecture emphasizes the importance of pharmacotherapy for osteoporosis and rheumatoid arthritis, highlighting treatments like bisphosphonates, selective estrogen receptor modulators, and disease-modifying antirheumatic drugs to manage these conditions effectively. Key patient education points include monitoring calcium and vitamin D intake, recognizing symptoms of side effects, and ensuring regular follow-up for monitoring and adjusting therapies.

Insights

  • The lecture highlights that osteoporosis is the most common metabolic bone disease, particularly affecting postmenopausal women, and is characterized by the weakening of bones due to decreased osteoclast activity. This condition often goes unnoticed until symptoms like back pain arise, and screening through DEXA scans is crucial for monitoring its progression.
  • Patients using proton pump inhibitors (PPIs) for extended durations face an elevated risk for developing osteoporosis, which underscores the importance of reviewing their medication regimens and considering discontinuation if they already show signs of reduced bone density, known as osteopenia.
  • Effective treatment for osteoporosis includes a combination of calcium and vitamin D supplementation, bisphosphonates, and selective estrogen receptor modulators (SERMs), with an emphasis on educating patients about dietary sources of calcium and the significance of maintaining adequate vitamin D levels for optimal calcium absorption and overall bone health.

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Recent questions

  • What is osteoporosis and its causes?

    Osteoporosis is a metabolic bone disease characterized by decreased bone density and increased fragility, leading to a higher risk of fractures. It is most prevalent in postmenopausal women due to hormonal changes that affect bone resorption and formation. The condition often arises from an imbalance between bone resorption by osteoclasts and bone formation by osteoblasts, resulting in weakened bones. Factors contributing to osteoporosis include aging, hormonal changes, nutritional deficiencies (particularly calcium and vitamin D), and certain medications, such as long-term use of proton pump inhibitors. While osteoporosis can be asymptomatic, it may present with back pain that worsens with activity. Regular screening through DEXA scans is essential for early detection and management.

  • How can I prevent osteoporosis?

    Preventing osteoporosis involves a multifaceted approach focusing on lifestyle modifications and nutritional support. Key strategies include ensuring adequate intake of calcium and vitamin D, which are crucial for bone health and calcium absorption. Adults should consume calcium-rich foods such as dairy products, green leafy vegetables, and fortified foods. Engaging in weight-bearing exercises, like walking or climbing stairs, is also vital for maintaining bone density. Additionally, avoiding smoking and limiting alcohol consumption can further reduce risk. For those at higher risk, such as postmenopausal women, healthcare providers may recommend medications like bisphosphonates or SERMs to help prevent bone loss. Regular check-ups and screenings are important to monitor bone health and make necessary adjustments to prevention strategies.

  • What are the symptoms of hypercalcemia?

    Hypercalcemia, a condition characterized by elevated calcium levels in the blood, can present with a variety of symptoms that may affect multiple systems in the body. Common symptoms include tachycardia (rapid heartbeat), hypertension (high blood pressure), and muscle weakness. Patients may also experience gastrointestinal issues such as constipation, nausea, and vomiting. Additionally, hypercalcemia can lead to neurological symptoms like lethargy and confusion. It is important for individuals to be educated about these signs, as early recognition and treatment are crucial to prevent complications. If symptoms arise, medical evaluation is necessary to determine the underlying cause and appropriate management, which may include hydration, medications, or addressing the primary condition leading to hypercalcemia.

  • What is the role of vitamin D in bone health?

    Vitamin D plays a critical role in maintaining bone health by facilitating the absorption of calcium in the intestines, which is essential for bone formation and remodeling. Adequate levels of vitamin D help ensure that calcium is effectively utilized in the body, preventing deficiencies that can lead to weakened bones and conditions like osteoporosis. The recommended daily intake of vitamin D increases with age, particularly after 70 years, to support ongoing bone health. Food sources rich in vitamin D include fatty fish, egg yolks, and fortified dairy products. For individuals who may not get enough vitamin D from diet or sunlight exposure, supplements are often recommended. Regular monitoring of vitamin D levels can help prevent deficiencies and support overall skeletal health.

  • What are disease-modifying antirheumatic drugs (DMARDs)?

    Disease-modifying antirheumatic drugs (DMARDs) are a class of medications used to treat autoimmune conditions like rheumatoid arthritis (RA) by slowing disease progression and preventing joint damage. These drugs work by modulating the immune system to reduce inflammation and improve patient outcomes. Methotrexate is the most commonly prescribed DMARD, known for its effectiveness in decreasing joint inflammation and damage. Patients on DMARDs require regular monitoring for potential side effects, including immunosuppression and liver toxicity. It is also important for patients to maintain hydration and avoid alcohol to minimize risks. Other DMARDs, such as hydroxychloroquine, may also be used, necessitating regular eye exams due to potential vision changes. Early initiation of DMARD therapy is crucial for optimal management of RA and to enhance the quality of life for affected individuals.

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Summary

00:00

Pharmacotherapy Strategies for Osteoporosis Management

  • The lecture focuses on pharmacotherapy for bone and joint disorders, specifically osteoporosis, as outlined in Adams chapter 48, emphasizing its prevalence in postmenopausal women and its status as the most common metabolic bone disease.
  • Osteoporosis is characterized by bone resorption due to a decrease in osteoclast activity, often asymptomatic but may present with back pain that worsens with activity and improves with rest; screening is conducted using DEXA scans to monitor progression.
  • Patients on proton pump inhibitors (PPIs) for extended periods are at increased risk for osteoporosis, necessitating careful review of their medication lists and potential discontinuation if they are already osteopenic.
  • Treatment for osteoporosis includes calcium and vitamin D supplementation, bisphosphonates, selective estrogen receptor modulators (SERMs), and calcitonin receptor agonists, with calcium and vitamin D being essential for bone health and calcium absorption.
  • Hypercalcemia symptoms include tachycardia, hypertension, muscle weakness, constipation, nausea, vomiting, lethargy, and confusion, while hypocalcemia may present as paresthesia, muscle twitches, spasms, and cardiac dysrhythmias, necessitating patient education on these signs.
  • Calcium supplements vary in elemental calcium content; for example, a 1,000 mg calcium carbonate tablet contains 400 mg of calcium, while a 1,000 mg calcium citrate tablet contains 200 mg, highlighting the importance of checking product labels for elemental calcium.
  • Common dietary sources of calcium include almond milk, dairy products, green leafy vegetables, fortified orange juice, cereals, and beans, and patients should be educated on these to prevent hypocalcemia.
  • Vitamin D is crucial for calcium absorption, with recommended daily intakes increasing from 400 IU to 600 IU after age 70; food sources include fish, egg yolks, and fortified dairy products, and supplements often combine calcium and vitamin D.
  • Bisphosphonates, such as alendronate, are used to prevent and treat osteoporosis, requiring administration with water and the patient to remain upright for 30 minutes post-dose to avoid esophagitis; monitoring for vision changes and muscle pain is also necessary.
  • Patients should be instructed to notify healthcare providers of any swallowing difficulties, persistent musculoskeletal pain, or gastrointestinal symptoms, and to avoid taking two doses of alendronate on the same day if a dose is missed, as it has a long half-life and is poorly absorbed orally.

18:29

Medications for Osteoporosis Gout and Arthritis

  • Raloxifene is a selective estrogen receptor modulator (SERM) commonly prescribed for postmenopausal osteoporosis and to reduce the risk of estrogen receptor-positive breast cancer, posing less risk of uterine cancer compared to tamoxifen.
  • Raloxifene is taken orally once daily, with or without food, and may cause estrogen-associated side effects such as hot flashes, stroke, and increased risk of deep vein thrombosis (DVT), which can lead to pulmonary embolism.
  • Patients on raloxifene should be monitored for DVT symptoms, including unilateral swelling, redness, and pain, and should report calf pain or difficulty breathing immediately to their healthcare provider.
  • Patients are advised to avoid estrogen replacement therapy while on a SERM, maintain adequate calcium and vitamin D intake, and engage in weight-bearing exercises like walking or climbing stairs; it is contraindicated in pregnant individuals and those with a history of DVT.
  • Calcitonin, a bone resorption inhibitor, is used to treat established postmenopausal osteoporosis and hypercalcemia, acting similarly to the thyroid hormone by inhibiting osteoclast activity and increasing calcium excretion.
  • Calcitonin can be administered intranasally or via intramuscular/subcutaneous injection, with an allergy test recommended before therapy; monitor for hypocalcemia symptoms such as muscle spasms and tingling, and ensure a diet high in calcium and vitamin D.
  • For intranasal administration, assess for nasal irritation, and if given parenterally, protect from light and refrigerate; contraindications include allergy to salmon and prior treatment with bisphosphonates.
  • Gout treatment involves using NSAIDs like indomethacin and naproxen for acute attacks, while corticosteroids may be used for inflammation in single joints; chronic gout management includes medications that lower serum uric acid levels, such as probenecid and allopurinol.
  • Allopurinol, a xanthine oxidase inhibitor, prevents uric acid formation and is effective in reducing acute gout attacks and preventing kidney stones; it requires monitoring of uric acid levels and hydration of at least three liters daily to prevent nephrotoxicity.
  • Rheumatoid arthritis (RA) is an autoimmune condition characterized by joint inflammation and systemic symptoms; treatment includes NSAIDs and corticosteroids to manage pain and inflammation, with attention to potential side effects like GI bleeding and heartburn.

36:31

Monitoring and Management of RA Medications

  • Patients taking chronic anti-acids should be monitored for darkened stools, as this could indicate bleeding. Additionally, corticosteroids can lead to infections and hypoglycemia, necessitating close observation for these symptoms in patients receiving these medications.
  • Disease-modifying antirheumatic drugs (DMARDs) are essential in managing rheumatoid arthritis (RA), with early therapy being the standard of care to slow tissue damage and improve patient outcomes. Methotrexate is the primary DMARD used, which decreases joint inflammation and damage but requires monitoring for immunosuppression, including decreased platelet and white blood cell counts.
  • Methotrexate is typically administered once a week, either via injection or orally, and patients should also take folic acid to reduce toxicity risks. It is crucial for patients to drink at least 2 liters of water daily to aid in drug excretion and to report any yellowing of the skin, which may indicate hepatotoxicity. Alcohol and caffeine should be avoided due to their adverse effects on the drug's efficacy and safety.
  • Hydroxychloroquine, an antimalarial agent also used as a DMARD, requires patients to undergo yearly eye exams due to potential vision changes. Regular complete blood counts (CBC) should be monitored to check for granulocytosis and immunosuppression, and like methotrexate, alcohol should be avoided.
  • Monoclonal antibodies, such as abatacept and others ending in "mab," work by inactivating tumor necrosis factor to reduce inflammation in RA. These are typically administered weekly via injection and require monitoring for infections and injection site reactions. Patients must be up to date on vaccinations and should not receive live vaccines due to the risk of activating latent infections.
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