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FM40 Family Medicine
Common Presenting Problems Toronto Notes 2019
Menopause/Hormone Replacement Therapy
• seeGynecology,GY33 Epidemiology
• meanageofmenopause=51.4yr
Clinical Features
• associatedwithestrogendeprivation
• urogenitaltract:atrophy,vaginaldryness/itching,urinaryfrequency/urgency/incontinence,bleeding • vascular: vasomotor instability (e.g. hot flashes), increased risk of heart disease
• bones:boneloss,joint/muscle/backpain,fractures,lossofheight
• brain:depression,irritability,moodswings,memoryloss
Management
• non-pharmacologicalmanagement:encouragephysicalexercise,smokingcessation,andabalanceddiet
Glucosamine Therapy for Treating Osteoarthritis
Cochrane Database Syst Rev 2005;2:CD002946
Purpose: To evaluate the effectiveness and toxicity of glucosamine in osteoarthritis (OA) treatment.
Methods: Meta-analysis of RCTs evaluating effectiveness and safety of glucosamine relative to other interventions or placebo in OA treatment.
Results: 20 analyzed RCTs found glucosamine was superior to placebo with a 28% improvement in pain (standardized mean difference (SMD) -0.61, 95% CI -0.95 to -0.28) and a 21% improvement in function using the Lequesne index (SMD -0.51, -0.96 to 0.05). No statistically significant difference was found in terms of WOMAC
pain, function and stiffness. In trials comparing a Rotta preparation of glucosamine to placebo, a statistically significant improvement in pain (SMD -1.31, -1.99 to -0.64 and function using the Lequesne index (SMD -0.51, -0.96 to -0.05) was seen, whereas those using a non-Rotta preparation did not show a significant difference for
pain (SMD -0.15, -0.35 to 0.05) or function (SMD 0.03, -0.18 to 0.25). Compared to NSAIDs, Rotta preparation
of glucosamine was found to be superior in 2 studies, showing slowing of radiological progression of knee OA over 3 years – SMD 0.24, 0.04 to 0.43), and equivalent in 1 study. Glucosamine was found to be comparable to placebo in number of participants reporting adverse reactions (risk ratio (RR) 0.97, 0.88 to 1.08).
Conclusion: While non-Rotta preparation of glucosamine did not show benefit in pain and WOMAC function, Rotta preparation was superior to placebo in treating pain and functional impairment associated with symptomatic
OA. WOMAC pain, stiffness and function did not show significant differences between glucosamine and placebo for either glucosamine preparation. Glucosamine was found to be equally safe compared to placebo.
•
with adequate intake/supplementation of calcium (1,200-1,500 mg/d) and vitamin D (800-2,000 IU/d) pharmacologicalmanagement:
■ hormone replacement therapy (HRT)
◆ initiation of HRT requires a thorough discussion of short- and long-term benefits and risks
◆ prescribe for moderate to severe symptoms for no longer than 5 yr; routine use is not
recommended
◆ regimens: cyclic or continuous estrogen-progestin, estrogen only (if no uterus, -patch/gel/cream/
ring/vaginal tablet)
◆ advantages: decreases risk of osteoporotic fractures, colorectal cancer
◆ disadvantages: increases risk of breast cancer, coronary heart disease, stroke, DVT, and PE
■ venlafaxine, SSRIs, or gabapentin to ease vasomotor instability
Osteoarthritis
seeRheumatology,RH5
•
• Hand (DIP, PIP, 1st CMC)
• Hip
• Knee
• 1st MTP
• L-spine (L4-L5, L5-S1)
• C-spine
• Uncommon: ankle, shoulder,
elbow, MCP, rest of wrist
Figure 14. Common sites of involvement in OA
Epidemiology
• mostcommonformofarthritisseeninprimarycare
• prevalenceis10-12%andincreaseswithage
• resultsinlong-termdisabilityin2-3%ofpatientswithOA
• almosteveryoneovertheageof65showssignsofOAonx-ray,butonly33%oftheseindividualswillbe
symptomatic
Clinical Features
• jointpainwithactivity,improvedwithrest,morningstiffnessorgelling<30min
• deformity,bonyenlargement,crepitus,limitationofmovement,peri-articularmuscleatrophy • usuallyaffectsdistaljointsofhands,spine,hips,andknees
Investigations
• nolaboratorytestsforthediagnosisofOA
• hallmarkradiographicfeatures:jointspacenarrowing,subchondralsclerosis,subchondralcysts,
osteophytes
Management
• goals:relievepain,preservejointmotionandfunction,preventfurtherinjury • conservative
■ patient education, weight loss, low-impact exercise (OT/PT), assistive devices (e.g. canes, orthotics) • pharmacological
■ consider comorbidities such as PUD, HTN, IHD, hepatic disease, and renal disease ■ medications do not alter natural course of OA
■ 1st line: acetaminophen up to 4 g/d (OA is not an inflammatory disorder)
■ 2nd line: NSAIDs (COX-2 selective) in low doses for short durations
■ 3rd line: combination analgesics (e.g. acetaminophen and codeine) ■ other pharmacological adjuncts:
◆ intra-articular corticosteroid or hyaluronic acid injections ◆ topical NSAIDS (diclofenac)
◆ capsaicin cream
◆ oral glucosamine
• surgery
■ consider if persistent significant pain and functional impairment despite optimal pharmacotherapy
(e.g. debridement, osteotomy, total joint arthroplasty)
© Linda Colati