1. Osteoarthritis Ahmed Shaman Department of Clinical Pharmacy shaman@ksu.edu.sa

2. 1.Osteoarthritis (OA)

3. Osteoarthritis (OA) Most common form of arthritis (6% of adults) Degenerative disease of weight-bearing joints – Joint pain, reduced range of motion and brief joint stiffness after inactivity – Hips & knees, but also hands – Risk factors: Strongly related to age (10-15% of > 60 yo) Biomechanical stress (repetitive high-impact) Increased risk if overweight (10% per 1 kg > IBW)

4. Goals of Therapy for OA Educate patient & caregivers Relieve pain Maintain or restore mobility Minimize functional impairment Preserve joint integrity Improve quality of life

5. Non-Pharmacologic Treatment of OA Patient education for lifestyle modification – Aerobic exercise w/stretching & strength training Low impact isometric 3-4 times / week – Yoga, water aerobics, walking – Weight loss via diet and exercise – Physical or occupational therapy Heat or cold treatments of affected joints Joint-replacement surgery

6. Pharmacologic Treatment of OA First Line Acetaminophen (paracetamol) – 1 st line therapy due to effectiveness & safety As effective as NSAIDs for mild to moderate joint pain – Up to 4 g (3 g safer) daily in divided doses Scheduled doses better, need 4-6 week trial NSAIDs – Reasonable alternative after acetaminophen – Usual NSAID problems (GI, renal, and cardiovascular adverse events)

7. Other Pharmacotherapy for OA First Line Topical therapy – NSAIDs for superficial joints (Knees,hands) – Capsaicin (takes 2 weeks) Steroids – Intraarticular Tramadol – As effective as NSAIDs – May be added to NSAIDs or Acetaminophen

8. Alternative Therapies for OA Second Line Opioids for severe / refractory disease Duloxetine – adjunctive treatment in patients with a partial response to first-line analgesics Hyaluronic Acid Intra-articular (?efficacy) – increased pain, joint swelling, and stiffness – Not recommended for routine use Glucosamine & Chondroitin – Controversial efficacy, not recommended to use – Trial for 3 – 6 months

10. 2.Urinary Incontinence

11. Urinary Incontinence Defined as the complaint of involuntary leakage of urine 30% of older adults, women 2 x men Pelvic surgery, childbirth et al Reversible causes: DRIPP – Delirium – Restricted mobility – Infection – Inflammation (atrophic vaginitis) – Impaction of feces – Polyuria (diabetes, caffeine intake, volume overload) – Pharmaceuticals Diuretics, alpha adrenergic agonists/antagonists, anticholinergics

12. Stress Incontinence Urethra and/or urethral sphincters underactivity Pelvic surgery, childbirth, vaginal atrophy – Coughing, laughing, sneezing – Rx Surgery or pelvic muscle exercises (the best) – Vaginally administered estrogen for atrophic urethritis or vaginitis

13. Urge Incontinence Detrusor overactivity (gotta go!) – Most common form – Uninhibited bladder contractions – Large volumes, nocturnal (sleep disturbances) – Bladder retraining by voiding Q2h Anticholinergics (1 st line) can be added (relaxes bladder) – Oxybutinin, Tolterodine (better tolerated) – Urinary retention, confusion, constipation, dry mouth – Orthostatic hypotension, tachycardia

14. Overflow Incontinence Dribbling after voiding Bladder cannot be emptied completely and large volumes of residual urine remain after micturition Bladder outlet obstruction or atonic bladder – Prostatic hypertrophy, prostate cancer & urethral strictures – Spinal cord disease, autonomic neuropathy (neurogenic bladder) Diabetes, alcoholism, B12 deficiency, Parkinson's – Removal of obstruction (surgical) – Intermittent catheterization 3 – 4 times daily

15. Overflow Incontinence Cholinomimetic bethanecol (25–50 mg three or four times daily) is of uncertain effect but may be trialed – Muscle and abdominal cramping, hypersalivation, diarrhea, and potentially life-threatening bradycardia and bronchospasm α-adrenoceptor antagonists such as silodosin, prazosin, terazosin, doxazosin, tamsulosin, and alfuzosin may benefit this condition by relaxing the bladder outflow tract and hence reducing outflow resistance Less satisfactory alternatives include indwelling urethral or suprapubic catheters

16. 3.Benign Prostatic Hyperplasia

17. Males with BPH Alpha 1 adrenergic blockers (rapid effect) – Relaxes muscles of bladder neck, urethra – Decrease symptoms (nocturia) – First-line treatment for moderate to severe BPH – Terazosin, Doxazosin or Tamsulosin, Alfuzosin – 30% to 80% improve in symptoms – Hepatically cleared, use lowest possible dose in liver d/o – 1 st dose hypotension; give at bed time titrate up slowly (q3-7 days)

18. Males with BPH 5 alpha reductase inhibitor (monotherpy) – Block conversion of testosterone to dihydrotestosterone – Reduces prostate volume and decrease progression – Finasteride, Dutasteride – A minimum of 6 months is required to evaluate the effectiveness of treatment – Produce a mean 50% decrease in serum levels of PSA – Combined with doxazosin if volume > 25 mL – Adverse effects include decreased libido, erectile dysfunction, and ejaculation disorders, gynecomastia and breast tenderness

19. Combination Therapy α-adrenergic antagonist + 5α-reductase inhibitor may be considered in symptomatic patients at high risk of BPH complications – Enlarged prostate of at least 30 g – PSA of at least 1.5 ng/mL Relieve voiding symptoms Reduce the risk of developing BPH-related complications Reduce the need for prostatectomy by 67%

20. Severe BPH Prostatectomy; transurethrally, open surgery – For complications of BPH disease Recurrent urinary tract infection, urosepsis, urinary incontinence, refractory urinary retention, chronic renal failure, recurrent severe gross hematuria – May lead to erectile dysfunction, retrograde ejaculation, urinary incontinence, bleeding, or urinary tract infection Drug treatment is used in inoperable patients with severe disease