1. OA

2. W.F. is an 85-year-old man who presents to his physician with pain from hip on one side. He also has hypertension, coronary artery disease, and BPH. For his hip pain, W.F. has been taking acetaminophen 650 mg 3 times/day. W.F. reports that the acetaminophen helps, but he still experiences pain that limits his ability to walk.
SOAP
Goal of therapy
Your recommendation for monitoring recommended therapy.

3. The major goals for the management of OA are to (1) educate the patient, caregivers, and relatives; (2) relieve pain and stiffness; (3) maintain or improve joint mobility; (4) limit functional impairment; and (5) maintain or improve quality of life.

4. To monitor efficacy, the patient’s baseline pain can be assessed with a visual analog scale, and range of motion for affected joints can be assessed with flexion, extension, abduction, or adduction. • Depending on the joint affected, measurement of grip strength and 50-feet walking time can help assess hand and hip/knee OA, respectively. • Baseline radiographs can document the extent of joint involvement and follow disease progression with therapy. • Other measures include the clinician’s global assessment based on the patient’s history of activities and limitations caused by OA, the Western Ontario and McMaster Universities Arthrosis Index, Stanford Health Assessment Questionnaire, and documentation of analgesic or NSAID use.

5. Patients should be asked if they are having adverse effects from their medications. They should also be monitored for any signs of drug-related effects, such as skin rash, headaches, drowsiness, weight gain, or hypertension from NSAIDs. • Baseline serum creatinine, hematology profiles, and serum transaminases with repeat levels at 6- to 12-month intervals are useful in identifying specific toxicities to the kidney, liver, GI tract, or bone marrow.

6. Which one of the following is the best next step in analgesic therapy for W.F.? A. Change the analgesic to celecoxib. B. Add hydrocodone. C. Change the analgesic to ibuprofen. D. Add glucosamine.

7. Answer B The AGS recommends treatment with opioids for OA when older patients do not respond to initial therapy with acetaminophen.
The NSAIDs and COX-2 inhibitors are seldom considered when a thorough assessment of the patient shows that the risk of treatment (gastrointestinal bleeding and renal disease) does not outweigh the potential benefit. Glucosamine can be added to this patient's medication regimen; however, if effective, it will not provide immediate relief of pain.