NURS 6521 wk 6 Essay Discussion
Pharmacotherapy of Endocrine and Musculoskeletal Disorders
Osteoarthritis is a common disorder frequently encountered in primary care practice affecting approximately 30 million patients within the U.S. (Centers for Disease Control and Prevention). Advance practice nurses must be familiar with diagnosing and treating this ailment effectively in the outpatient setting.NURS 6521 wk 6 Essay Discussion
The Disease
Osteoarthritis is characterized by degeneration of articular joint cartilages, decreasing production of synovial fluid, and ultimately impairing function of the affected joint (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Diagnosis is based on the American Collage of Rheumatology (ACR) diagnostic criteria with further specificity based on the affected joint. General symptoms include pain, stiffness, crepitus, tenderness, and pain with movement or that radiates. Physical symptoms include Heberden’s nodules to distal joints, joint effusion or enlargement, decreased range of motion, joint contractures, and progressive worsening.
Initiating Treatment
Osteoarthritis treatment goals are to decrease pain/discomfort, improve functionality, and prevent further progression of the disorder. Severity at the time of diagnosis can lead the prescribers plan of treatment and the level of aggressive treatment.
First line treatment in mild to moderate OA begins with nonpharmacological therapies and Acetaminophen 1GM every 6 to hours. Acetaminophen has very few interactions and is very effective in mild analgesia and anti-inflammatory. Alternative medications that can be used as first line include over the counter products, such as Icy Hot or capsaicin products. Prescription topical NSAIDS such as Diclofenac can also be used as adjunct therapy for localized improvement.
Second line treatment includes NSAIDs. NSAIDs are classified due to their individual structures and provided both analgesia and anti-inflammatory properties. NSAIDs block pain and inflammation mediators as well as interfering with COX 1 & 2 enzymes. Some NSAIDs are enzyme specific and others are nonspecific leading to more adverse effects with medication use. Common NSAIDs used are ibuprofen, Celebrex, Diclofenac, and Naprosyn. Pt response to NSAIDs vary and each individual patient may react differently to medication within the same class.NURS 6521 wk 6 Essay Discussion
Third line treatment for patients not tolerating or ineffective with the first line treatment, pain analgesics, opioid or nonopioid pain medications can be initiated. Tramadol, Tapentadol are mu opiate receptor agonists that block ascending pain pathways decreasing the sensation of pain and affecting uptake of serotonin and norepinephrine leading to pain control. Duloxetine is another third line medication effecting serotonin and norepinephrine interrupting pain pathways in the brain. Duloxetine may take up to 4 weeks to show improvement. Finally, intra-articular corticosteroids can be injected into the joint in nonresponsive cases or acute flare-ups but should be used judiciously.
Individual Factor
Alcoholism and poor liver function can affect the treatment of OA by altering the pharmacokinetics and pharmacodynamics of medications within the body. NSAIDs are already an established initiator of GI complications such as GI bleed, however a patients excessive alcohol use can increase the risk for severe GI toxicity (Neutel & Appel, 2000). The most common affects of NSAIDS toxicity include GI concerns and renal and liver alterations of function.NURS 6521 wk 6 Essay Discussion
Liver failure has also been reported with acetaminophen use in alcoholic patients. Patients using acetaminophen for therapeutic use that consume alcohol can lead to hepatic failure, necrosis, and death (Kuffner, Green, Bogdan, Knox, et.al., 2007). Acetaminophen is metabolized within the liver and the CYP enzyme system. CYP2E1 induction and alcohol use results in increased accumulations and hepatotoxicity from nontoxic dosage levels (Tanaka, Tamazaki, & Misawa, 2000).
The importance of medical, familial, and social review cannot be stressed enough when prescribing medication therapy for patients as all individual factors specific to each patient can and does effect compliance, adverse reactions risk, and efficacy of therapy. Osteoarthritis treatment is a progressive disorder affected by multiple aspects of the patient’s lifestyle requiring specificity and individualized treatment.NURS 6521 wk 6 Essay Discussion