Grandma’s aching knees and snapping fingers LeeChuy, Katherine Lee, Sidney Abert Lerma, Daniel Joseph Legaspi, Roberto Jose Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John Harold Lim, Mary Lim, Phoebe Ruth Lim, Syndel Raina Lipana, Kirk Andrew Liu, Johanna Llamas, Camilla Alay

Pain and stiffness of thumb and middle finger of R hand 79 y/o F Chief Complaint Chronic knee pain Pain and stiffness of thumb and middle finger of R hand

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

Past Medical History Hypertension Osteoporosis Controlled on daily amlodipine Hypertension 2 yearly infusion of zoledronic acid Osteoporosis Zoledronic acid belongs to a class of drugs known as bisphosphonates. It works by reducing the amount of calcium released from your bones into your blood.

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

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

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

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

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

Osteoarthritis Patient Osteoarthritis 79 years old female leading cause of disability in the elderly BMI = 28 Obesity Painful knees; Crepitus on both knees without effusion affected joints include the cervical and lumbosacral spine, hip, knee. Painful knee on walking Joint 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

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.

Management for OA Exercise lessens pain and improves physical function consist of aerobic and/or resistance training (strengthens muscles across the joints)

Management for OA Correction of Malalignment (Genu Varus/Valgus) Leg brace Surgery

Management for OA

“Trigger-finger/digit” Patient Trigger-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

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

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

Osteoporosis Patient Osteoporosis 79 y/o Advanced age Female Female sex Estrogen deficiency Low calcium intake Alcohol and cigarette consumption

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. (1000 mg per day of calcium for adults under the age of 50 and 1200 mg per day for those ages 50 and older, which are the current recommended guidelines from the National Osteoporosis Foundation). (400-800 IU per day for adults younger than age 50, 800 to 1000 IU per day for those age 50 and older, which are the current recommended guidelines from the National Osteoporosis Foundation). Doses may need to be adjusted according to blood levels of vitamin D.

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.

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

What is the mechanism of action of NSAIDs?

NSAIDs 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.

MOA of NSAIDS

Selective and Non-Selective NSAID Stomach Kidney Platelets Endotheliumcc Macrophages Leukocytes Fibroblasts Endothelium

Bisphosphonate preparations Philippine Brands Primary indication Dose Route Alendronate Fosamax Osteoporosis 10 mg/day; 70mg/week Oral Risedronate Actonel 5 mg/day; 35 mg/week Ibandronate Bondronat, Bonviva 2.5 mg/day; 150mg/month Pamidronate Aredia Bone Metastasis 90mg/3 weeks IV Zoledronate Aclasta, Zometa 4mg/3 weeks Incadronate Bisphonal Bone metastasis 10mg/2weeks Clodronate Bonefos Pagets / Bone metastasis 1600-3200md/day 300mg/day

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