Bone and Joint Disorders Discussion

• To diagnose our patient, an arthrocentesis to aspirate synovial fluid should be completed.  If it is an acute gout flair, the fluid will likely appear yellow and cloudy.  Under microscopic examination, the presence of birefringent needle-shaped crystals will be visualized (Dalbeth et al., 2016).  Laboratory tests including a serum uric acid (SUA), CBC, serum creatinine, lipid panel, and ESR will be conducted.   The initial treatment for this patient would be the administration of anti-inflammatory medications such as NSAIDS or colchicine along with a proton pump inhibitor (Abhishek et al., 2017).  Additionally, ice will be applied to the affected joint and rest encouraged.
• Gout is a form of inflammatory arthritis in which monosodium urate crystals are deposited in joint spaces or surrounding tissue leading to a rapid and intensely painful inflammatory response (Dalbeth et al., 2016).  This chronic condition develops due to an increased amount of uric acid, known as hyperuricemia, either from overproduction or because it is not being adequately excreted in the urine.  It is more commonly caused through underexcretion. Bone and Joint Disorders Discussion
• As with any medication and/or supplement, there are risks and benefits that one must consider before beginning a new regimen.  The U.S. Preventative Services Task Force no longer recommends routine daily preventative calcium and vitamin D intake by post-menopausal women, defined as 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for the primary prevention of fractures (Kling et al., 2014).  They reasoned that the risk to benefit ratio regarding cardiovascular disease was unknown.  Conversely, the National Academy of Medicine, formerly known as the Institute of Medicine, recommends 1200 mg of calcium and 600 IU of vitamin D for women over the age of 50 (National Academy of Medicine, 2010).  Finally, evidence from the Women’s Health Initiative demonstrated no clinically significant cardiovascular effect with the combination of calcium and vitamin D and, conversely, found that low vitamin D levels were associated with increased cardiovascular risk factors, along with an increased risk of developing diabetes (Kling et al., 2014).
• Osteoporosis is a health problem that involves excessive bone resorption from osteoclasts with concurrent new bone formation from osteoblasts leading to bone fragility and an increased risk of fractures (Ibrahim et al., 2019).  This disease is often referred to as a silent disease as its discovery may occur upon an osteoporotic fracture.  The disease has many different risk factors, some of which are modifiable and others that are not.  Non-modifiable risk factors include female gender, age at onset of menopause, family history of osteoporosis, and race.  Factors that can be modifiable include calcium intake, soda, caffeine, weight-bearing exercise, decreased alcohol consumption, smoking, low body mass index, sunshine exposure, and certain drug use, such as corticosteroids. Bone and Joint Disorders Discussion

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• Pharmacology Discussion 6
• I would advise the patient that a T-score of -2.3 indicates osteopenia and is at risk for progressing to osteoporosis (Chisholm-Burns et al., 2019). Also, after menopause, decreases in her serum estrogen are contributing to diminishing bone mineral density (BMD), thus increasing the risk of fractures (Tarantino et al., 2017). Next, a history and physical should include a review of all past and current medications. It is well documented that diuretics and PPI’s when used by postmenopausal women over extended periods, also contribute to increased risk of fractures (Chen et al., 2016). Initial lab screenings should include CBC, chemistry, electrolytes, alkaline phosphatase, liver enzymes,  25-hydroxyvitamin-D3, and a urine calcium/24 hour. The results may indicate a secondary cause of osteopenia, such as CKD, diabetes, vitamin D deficiency, and hyperthyroidism (Tarantino et al., 2017). Also, a FRAX  risk score using her height and weight should be calculated in order to justify starting pharmacologic therapy. In combination with the T-score, I would recommend Alendondrate 5mg daily and review proper administration and side effects with her (Tarantino et al., 2017). Additionally, according to evidence-based studies, she needs at least 12000 mg of calcium and 800 IU of vitamin D per day (Chisholm-Burns et al., 2019). Dietary sources are preferred to supplements, and based on her average daily intake and labs, supplemental dosages are adjusted accordingly (Tabatabaei-Malazy et al., 2017). Lifestyle recommendations include smoking cessation, limiting alcohol intake, 30 minutes of daily weight-bearing exercise, and 15 minutes of direct sunlight daily (Tarantino et al., 2017).   Krabbe, J. P., & Lucente, M. (2020). Nutritional Management of a Patient with Recurrent Gout: A Case Report. Nutritional Perspectives: Journal of the Council on Nutrition, 43(3), 12–18.Richette, P., Doherty, M., Pascual, E., Barskova, V., Becce, F., Castaneda, J., . . . Bardin, T. (2020). 2018 updated European league against rheumatism evidence-based recommendations for the diagnosis of gout. Annals of the Rheumatic Diseases, 79(1), 31. doi:http://dx.doi.org.wilkes.idm.oclc.org/10.1136/annrheumdis-2019-215315Tabatabaei-Malazy, O., Salari, P., Khashayar, P., & Larijani, B. (2017). New horizons in the treatment of osteoporosis. Daru: journal of Faculty of Pharmacy, Tehran University of Medical Sciences, 25(1), 2. https://doi.org/10.1186/s40199-017-0167-zTarantino, U., Iolascon, G., Cianferotti, L., Masi, L., Marcucci, G., Giusti, F., Marini, F., Parri, S., Feola, M., Rao, C., Piccirilli, E., Zanetti, E. B., Cittadini, N., Alvaro, R., Moretti, A., Calafiore, D., Toro, G., Gimigliano, F., Resmini, G., & Brandi, M. L. (2017). Clinical guidelines for the prevention and treatment of osteoporosis: summary statements and recommendations from the Italian Society for Orthopaedics and Traumatology. Journal of orthopedics and traumatology: official journal of the Italian Society of Orthopaedics and Traumatology, 18(Suppl 1), 3–36. https://doi.org/10.1007/s10195-017-0474-7  Bone and Joint Disorders Discussion
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• Neogi, T., Jansen, T. L., Dalbeth, N., Fransen, J., Schumacher, H. R., Berendsen, D., Brown, M., Choi, H., Edwards, N. L., Janssens, H. J., Lioté, F., Naden, R. P., Nuki, G., Ogdie, A., Perez-Ruiz, F., Saag, K., Singh, J. A., Sundy, J. S., Tausche, A. K., Vazquez-Mellado, J., … Taylor, W. J. (2015). 2015 Gout Classification Criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis & rheumatology (Hoboken, N.J.), 67(10), 2557–2568. https://doi.org/10.1002/art.39254
• Chisholm-Burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Bookstaver, P. B., & Lee, K. C. (2019). Pharmacotherapy principles & practice. McGraw-Hill Education.
• Chen, C.-H., Lin, C.-L., & Kao, C.-H. (2016). Gastroesophageal reflux disease with proton pump inhibitor use is associated with an increased risk of osteoporosis: a nationwide population-based analysis. Osteoporosis International, 27(6), 2117–2126. https://doi-org.ezproxy.fau.edu/10.1007/s00198-016-3510-1

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• This gentleman appears to have had an attack of gout, which is a form of arthritis.  Since rheumatoid and osteoarthritis have similar symptoms, a thorough history and physical is done to rule out other possibilities (Richette et al., 2020). Male, patients with HTN, dyslipidemia, obesity, diabetes, and taking thiazide diuretics have increased risk factors for gout. In addition, gout often appears after the ingestion of purine-rich food and alcohol (Chisholm-Burns et al., 2019). Consequently, gout usually appears as joint tenderness, erythema, warmth, and swelling of the first metatarsophalangeal joint. However, it can affect other sites such as the wrist, elbow, knee, heel, and fingers (Richette et al., 2020). Since the patient is positive for several risk factors and describes the pain as increasing and peaking within 24 hours, I strongly suspect gout. The gold standard for confirmation is the aspiration of synovial fluid from the affected joint to confirm the presence of monosodium urate crystals. Alternatively, an ultrasound confirming the presence of a double contour sign can also confirm gout (Neogi et al., 2015). Unfortunately, drawing labs will not help identify gout at this time. The American College of Rheumatology  (ACR) does not recommend measuring serum urate levels until at least four weeks after an acute attack and while not on urate-lowering therapy (Neogi et al., 2015). Nutrition counseling should advise a diet with lower consumption of purines in order to prevent the progression of the disease. Unless diet modifications are made, painful attacks will usually affect more joints over time, causing permanent joint damage (Krabbe and Lucente, 2020). Furthermore, I would confer with his cardiologist to which blood pressure medication is the safest alternative for him. Lastly, I would recommend starting colchicine 0.5mg PO daily in combination with NSAIDs for acute attacks, ice, and elevation to the affected joint, and check serum urate levels in three months (Slobodnick et al., 2018). Bone and Joint Disorders Discussion
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• Shante Hunt posted Oct 7, 2020 7:37 PM
• Vitamin D and calcium supplementation are important for bone density health.  The risks of calcium supplementation include development of renal calculi and coronary artery disease including myocardial infarction.  Coronary risks have been noted to have a genetic component, where underlying genetic predisposition to higher serum calcium levels have been associated with increased incidents of myocardial infarction (Larsson et al, 2017).  Conversely, Kopecky et al (2016) found that there was not a significant increase in cardiovascular events and mortality from calcium supplementation for the treatment of osteoporosis, and maintain that supplementation should remain in the clinical guidelines.  My recommendation for a 59 year old, postmenopausal woman with a maternal familial history of osteoporosis and breast cancer would be to first begin with an inventory of her dietary intake of calcium.  If intake is found to be insufficient, I would recommend supplementation with Os-Cal 500 + D so that she meets the requirements for elemental calcium supplementation.  Due to her mother’s history of osteoporosis and her T-score of -2.3, I would recommend Fosamax 70 mg once a week provided that she has normal renal function (Felicilda-Reynaldo and Kenneally, 2019), and would include a work up for breast cancer markers to determine whether she may have additional risks to bone density from calcium leeching masses.  The patient with the acute attack of gout may have many risk factors that led to the event.  He reports that his symptoms began after eating dinner, and that he consumed a large amount of wine with his meal.  The patient should be educated that the risk of gout attacks increases with ingestion of foods high in purines and with consumption of alcohol.  The patient also has a past medical history of hypertension and takes HCTZ to manage the disease.  NSAID therapy is first-line treatment for acute gout but should be avoided in uncontrolled hypertension.  Since there is no evidence of uncontrolled HTN in this patient, I would recommend Naproxen 750 mg to start, then 250 mg every eight hours and add colchicine and educate on the GI symptoms to observe for.  Although there is some evidence that lifestyle modifications do not have a significant impact on decrease in gout attacks, I would still recommend abstaining from intake of alcohol (Palabindala, 2017).  This patient does not report any attacks other than this one, however the use of colchicine with NSAIDS shows greater reduction in pain episodes than with NSAID therapy alone (Palabindala, 2017).References:Felicilda-Reynaldo, R. & Kenneally, M. (2019). First-line medications for osteoporosis. MEDSURG Nursing, 28(6), 381-386. http://web.a.ebscohost.com.wilkes.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=9&sid=8a8bc705-60c1-4a04-99ea-807637e66d34%40sessionmgr4008 Kopecky, S., Bauer, D., Gulati, M., Nieves, J., Singer, A., Toth, P., Underberg, J., Wallace, T., & Weaver, C. (2016). Lack of evidence linking calcium with or without Vitamin D supplementation to cardiovascular disease in generally healthy adults: a clinical guideline from the National Osteoporosis Foundation and the American Society for Preventive Cardiology. Annals of Internal Medicine, 165(12), 867-868. Bone and Joint Disorders Discussion  Doi: http://dx.doi.org.wilkes.idm.oclc.org/10.7326/M16-1743Larsson, S., Burgess, S., & Michaelsson, K. (2017). Association of genetic variants related to serum calcium levels with coronary artery disease and myocardial infarction. JAMA: Journal of the American Medical Association, 318(4), 371-380. Doi: http://dx.doi.org.wilkes.idm.oclc.org/10.1001/jama.2017.8981Palabindala, V. (2017). Guideline: in acute gout, steroids, NSAIDs, or low-dose colchicine recommended; lifestyle changes not supported. Annals of Internal Medicine, 166(4), 14. Doi: http://dx.doi.org.wilkes.idm.oclc.org/10.7326/ACPJC-2017-166-4-014 less0 UnreadUnread
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