1. Grandma’s aching knees and snapping fingers C1

2. Chief Complaint Pain and stiffness of thumb and middle finger of R hand 79 y/o F

3. History of Present Illness Years Painful knees, more pronounced on walking Recently Limited kitchen and cooking chores Pain and stiffness of thumb and middle finger of R hand Prescribed NSAID, temporary relief

4. Past Medical History Controlled on daily amlodipine Hypertension 2 yearly infusion of zoledronic acid Osteoporosis

5. Physical Examination Normal vital signs; BMI 28 Musculoskeletal Exam Crepitus on both knees without effusion 1 st and 3 rd fingers of R hand would snap on flexion and required assistance due to pain on attempted extension

6. Physical Examination Stooped posture Bilateral genu varum deformity Non-tender bony nodes on PIP and DIP

7. Salient Features 79 y/o female Years of painful knees, pronounced when walking Crepitus on both knees without effusion Bilateral genu varum Pain and stiffness of thumb and middle finger of R hand would snap on flexion and require assistance on extension Non-tender bony nodules on PIP and DIP Diagnosed with osteoporosis, received 2 yearly infusion of zoledronic acid Stooped posture Hypertension controlled on daily amlodipine

8. Musculoskeletal signs and symptoms in the Patient Painful knees, more pronounced on walking; Non- tender bony nodules on PIP and DIP; Crepitus on both knees without effusion; bilateral genu varum Pain and stiffness of thumb and middle finger of R hand; would snap on flexion and require assistance on extension Stooped posture; previous diagnosis of osteoporosis with prescribed medication

9. Musculoskeletal conditions in the Patient Osteoarthritis Painful knees, more pronounced on walking; Non-tender bony nodules on PIP and DIP; Crepitus on both knees without effusion; bilateral genu varum “Trigger Finger/ Digit” Pain and stiffness of thumb and middle finger of R hand; would snap on flexion and require assistance on extension Osteoporosis Stooped posture

10. Osteoarthritis PatientOsteoarthritis 79 years old femaleleading cause of disability in the elderly BMI = 28Obesity Painful knees; Crepitus on both knees without effusion affected joints include the cervical and lumbosacral spine, hip, knee. Painful knee on walkingJoint pain from OA is activity- related Non-tender bony nodules on PIP and DIP Presence of Heberden’s nodes in DIP and Bouchard’s nodes in PIP

11. Management for OA Non-pharmacologic Management (1) avoiding activities that overload the joint, as evidenced by their causing pain (2) improving the strength and conditioning of muscles that bridge the joint, so as to optimize their function (3) unloading the joint, either by redistributing load within the joint with a brace or a splint or by unloading the joint during weight bearing with a cane or a crutch. Exercise lessens pain and improves physical function consist of aerobic and/or resistance training (strengthens muscles across the joints) Correction of Malalignment

12. Management for OA

13. “Trigger-finger/digit” PatientTrigger-finger Pain and stiffness of thumb and middle finger of R hand would snap on flexion and require assistance on extension common disorder of later adulthood characterized by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain

14. Management for “Trigger-finger/digit” Local steroid injection – Cortisone, prednisolone, dexamethasone, and triamcinolone. – A mixture of steroid, 1% lidocaine, and 0.5% bupivacaine is used, in a ratio of 2:1:1, respectively – After injection, the patient is encouraged to move the digit. – A follow-up appointment is made for 3-4 weeks after the treatment

15. Management for “Trigger-finger/digit” Splinting – For those patients who decline injection – MCP joint is splinted in approximately 15° of flexion.

16. Osteoporosis PatientOsteoporosis 79 y/oAdvanced age FemaleFemale sex Estrogen deficiency Low calcium intake Alcohol and cigarette consumption

17. Management for Osteoporosis To maintain bone health: Make sure there is enough calcium in your diet Get adequate vitamin D intake, which is important for calcium absorption and to maintain muscle strength Get regular exercise, especially weight-bearing exercise.

18. Management for Osteoporosis Bisphophonates – alendronate, residronate, etidronate – Patient was given zoledronic acid Calcitonin – Calcitonin works by directly inhibiting osteoclast activity via the calcitonin receptor. – Calcitonin directly induces inhibition of osteoclastic bone resorption by affecting actin cytoskeleton which is needed for the osteoclastic activity.

19. Management for Osteoporosis Selective Estrogen Receptor Modulators (SERMs) – are a class of medications that act on the estrogen receptors throughout the body in a selective manner – Raloxifene (60 mg/d) - act on the bone by slowing bone resorption by the osteoclasts

20. What is the mechanism of action of NSAIDs?

21. Most NSAIDs act as nonselective inhibitors of the enzyme cyclooxygenase(COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes. COX catalyzes the formation of prostaglandins and thromboxane from arachidonic acid Prostaglandins act as messenger molecules in the process of inflammation.

22. Many aspects of the mechanism of action of NSAIDs remain unexplained, for this reason further COX pathways were hypothesized. The COX pathway was believed to fill some of this gap but recent findings make it appear unlikely that it plays any significant role in humans and alternative explanation models are proposed. The FASEB journal : official publication of the Federation of American Societies for Experimental Biology 22 (2): 383–390

23. MOA of NSAIDS

24. Selective and Non-Selective NSAID

25. Philippine Brands Primary indication DoseRoute AlendronateFosamaxOsteoporosis10 mg/day; 70mg/week Oral RisedronateActonelOsteoporosis5 mg/day; 35 mg/week Oral IbandronateBondronat, Bonviva Osteoporosis2.5 mg/day; 150mg/month Oral PamidronateArediaBone Metastasis 90mg/3 weeksIV ZoledronateAclasta, Zometa Bone Metastasis 4mg/3 weeksIV IncadronateBisphonalBone metastasis 10mg/2weeksIV ClodronateBonefosPagets / Bone metastasis 1600-3200md/dayOral 300mg/dayIV Bisphosphonate preparations

26. Thank You!