Morning Report Unknown

1
Morning ReportUnknown 82
2

• A 63 year old man with hyperlipidemia, arthritis
  and congestive heart failure (EF 25) is seen for
  worsening arthralgias. He complains of pains in
  his hips and knees for 15 years, which have now
  become worse. X-rays of the hips and knees have
  shown changes consistent with osteoarthritis
  serologic testing for rheumatologic causes have
  been negative.
• His cardiovascular status is stable, and he has
  no other complaints.
• He rates his pain as 6 on a scale of 1 to 10, but
  states he is not interested in joint replacement
  surgery at this time.

3

• Exam shows mild inflammation and swelling in the
  periarticular areas of both knees, and modestly
  limited range of motion of hips and knees because
  of pain.

4

• Complete blood count is shown below
• WBC 9.5
• Hb 14 (HCT 42)
• Plt 252K
• Normal WBC differential
• Basic metabolic testing

138
101
32
106
3.8
25
1.4
5
Which of the following treatments would you avoid
in this patient?

• A) Physical therapy for strength and range of
  motion
• B) Acetaminophen
• C) Tramodol
• D) Naproxen
• E) Corticosteroid injections

6
Which of the following treatments would you avoid
in this patient?

• A) Physical therapy for strength and range of
  motion
• B) Acetaminophen
• C) Tramodol
• D) Naproxen
• E) Corticosteroid injections

7
NSAIDs in chronic heart failure

• Relatively contraindicated in CHF, should be
  avoided
• May cause worsening of preexisting CHF
• Increase afterload by systemic vasoconstriction
• May blunt the renal effects of diuretics
• May cause renal dysfunction
• Especially in patients with severe LV dysfunction
  or underlying renal insufficiency
• May reverse the unloading effect of ACE
  inhibitors
• Increased CHF exacerbations hospitalizations
  seen in patients with CHF who start NSAIDs

8
Treatment of osteoarthritis

• Range of motion / PT / weight loss always!
• Anangesics, not necessarily antiinflammatories
  are the mainstay of pain control
• Acetaminophen
• Tramodol
• Opioids
• NSAIDs ok, unless contraindicated
• Intraarticular glucocorticoids
• appropriate in patients with OA who have one or a
  few painful joints, and in patients with
  monoarticular or pauciarticular inflammatory
  osteoarthritis in whom NSAIDs are contraindicated
  

OBJECTIVE recall that NSAIDs are contraindicated
in a patient with chronic heart failure.