Pharmacotherapy of Osteoarthritis — MCQs
All are true about osteoarthritis, except
Which enzyme is irreversibly inhibited by aspirin?
Which of the following is an absolute contraindication to the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?
Hydrocortisone Acetate is injected in a painful arthritic TMJ to?
A 65-year-old lady presented with a swollen and painful knee. On examination, she was found to have grade III osteoarthritic changes. What is the best course of action?
A drug that is effective for rheumatoid arthritis but is not appropriate for osteoarthritis is :
Mrs. Katson, a 64-year-old obese woman with bilateral knee osteoarthritis, describes pain on most days and limiting pain at least 2 days per week. She has tried activity modification (walking less) without success. All of the following therapies have been shown to be efficacious EXCEPT:
Primary osteoarthritis affects all except:
Osteoarthritis is typically not seen in which of the following joints?
Frieberg's disease involves which of the following?
Pharmacotherapy of Osteoarthritis Indian Medical PG Practice Questions and MCQs
Question 1: All are true about osteoarthritis, except
- A. Quadriceps atrophy (Correct Answer)
- B. MCP is spared
- C. Glucosamines are beneficial
- D. Loose bodies in the ankle joint
Explanation: ***Quadriceps atrophy*** - While muscle weakness can occur in osteoarthritis due to pain and disuse, **quadriceps atrophy** is not a universal or defining characteristic of the disease itself, nor is it consistently observed as a primary feature. - The statement implies that quadriceps atrophy is *always* true about osteoarthritis, which is incorrect as it's a potential consequence but not inherently present in all cases or a direct pathological feature. *MCP is spared* - The **metacarpophalangeal (MCP) joints** are typically spared in osteoarthritis, unlike in rheumatoid arthritis. - Osteoarthritis predominantly affects the **distal interphalangeal (DIP)** and **proximal interphalangeal (PIP)** joints of the hands, as well as the **carpometacarpal (CMC) joint of the thumb**. *Glucosamines are beneficial* - **Glucosamine sulfate** is a commonly used supplement in osteoarthritis, with some studies suggesting it may provide modest pain relief and slow cartilage degradation in certain patients. - While its efficacy is debated and not universally accepted as curative, many patients report subjective benefit, and it is considered a complementary therapy. *Loose bodies in the ankle joint* - **Loose bodies**, also known as joint mice, are fragments of cartilage or bone that can break off and float within the joint space. - These are a recognized complication of osteoarthritis, particularly in weight-bearing joints like the **ankle**, and can cause locking or catching sensations.
Question 2: Which enzyme is irreversibly inhibited by aspirin?
- A. Lipooxygenase
- B. Cyclooxygenase (Correct Answer)
- C. Thromboxane synthase
- D. Phospholipase
Explanation: ***Cyclooxygenase*** - **Aspirin** irreversibly inhibits **cyclooxygenase (COX-1 and COX-2)** by acetylating a serine residue in the enzyme's active site. - This irreversible inhibition prevents the production of **prostaglandins, thromboxane**, and **prostacyclin**, thereby reducing inflammation, pain, fever, and platelet aggregation. *Lipooxygenase* - **Lipooxygenase** is involved in the synthesis of **leukotrienes**, which are mediators of inflammation and allergic responses. - Aspirin does not directly inhibit lipooxygenase; rather, it primarily targets the COX pathway. *Thromboxane synthase* - **Thromboxane synthase** is an enzyme downstream of COX, responsible for converting prostaglandin H2 into **thromboxane A2**. - While aspirin's effect on platelet aggregation is due to reduced thromboxane A2 synthesis via COX inhibition, it does not directly inhibit thromboxane synthase itself. *Phospholipase* - **Phospholipase A2** is responsible for releasing **arachidonic acid** from cell membrane phospholipids, which is the initial step in both the cyclooxygenase and lipooxygenase pathways. - Aspirin does not directly inhibit phospholipase A2; its action occurs later in the cascade.
Question 3: Which of the following is an absolute contraindication to the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A. Asthma
- B. Rheumatoid arthritis
- C. Hypertension
- D. Active peptic ulcer disease (Correct Answer)
Explanation: ***Active peptic ulcer disease*** - NSAIDs **inhibit cyclooxygenase (COX)** enzymes, which are responsible for producing **prostaglandins** that protect the gastric mucosa. - In patients with **active peptic ulcers**, this inhibition can lead to serious complications like **bleeding** or **perforation**, making it an **absolute contraindication**. - A history of peptic ulcer disease is a relative contraindication, but active disease is an absolute contraindication. *Asthma* - While NSAIDs can exacerbate asthma in susceptible individuals (**NSAID-exacerbated respiratory disease or aspirin-exacerbated respiratory disease**), it is usually a **relative contraindication** rather than an absolute one. - This reaction typically affects a specific subset of asthmatic patients (around 10-20%) with aspirin sensitivity and nasal polyps. *Rheumatoid arthritis* - NSAIDs are commonly used to **manage pain and inflammation** associated with rheumatoid arthritis. - It is a condition where NSAIDs are **indicated** for symptom relief, not a contraindication. *Hypertension* - NSAIDs can contribute to **elevated blood pressure** due to their effects on renal prostaglandin synthesis, leading to sodium and water retention. - Although NSAIDs should be used cautiously in hypertensive patients, it is considered a **relative contraindication**, requiring close monitoring rather than an absolute prohibition.
Question 4: Hydrocortisone Acetate is injected in a painful arthritic TMJ to?
- A. Lubricate the synovial joint
- B. Decrease the inflammatory response (Correct Answer)
- C. Anaesthetize the nerve supply
- D. Increase the blood supply
Explanation: ***Decrease the inflammatory response*** - **Hydrocortisone Acetate** is a **corticosteroid**, well-known for its potent anti-inflammatory properties. - Injecting it directly into an arthritic temporomandibular joint (TMJ) helps to reduce local inflammation, thereby alleviating pain and improving joint function. *Lubricate the synovial joint* - While lubrication is important for joint function, **hydrocortisone acetate** does not act as a lubricant like hyaluronic acid. - Its primary mechanism is based on immune modulation and anti-inflammatory effects, not physical lubrication. *Anaesthetize the nerve supply* - **Hydrocortisone acetate** is not a local anesthetic; it does not directly block nerve impulses to provide immediate pain relief through numbness. - Although it reduces pain, this is secondary to its anti-inflammatory action rather than direct neural blockade. *Increase the blood supply* - **Corticosteroids** generally have vasoconstrictive properties, meaning they can *decrease* blood flow rather than increasing it, especially at the site of inflammation. - Increasing blood supply is not a therapeutic goal in managing acute inflammation in an arthritic joint.
Question 5: A 65-year-old lady presented with a swollen and painful knee. On examination, she was found to have grade III osteoarthritic changes. What is the best course of action?
- A. Conservative management
- B. Total knee replacement (Correct Answer)
- C. Arthroscopic washing
- D. Partial knee replacement
Explanation: ***Total knee replacement*** - For **grade III osteoarthritis** in a 65-year-old, a total knee replacement is the most definitive and effective treatment to relieve pain and restore function in a severely damaged joint. - This procedure addresses widespread cartilage loss and structural changes typical of advanced osteoarthritis. *Conservative management* - This approach is typically favored for **mild to moderate osteoarthritis**, involving physical therapy, NSAIDs, and lifestyle modifications. - For **grade III changes** with significant pain and swelling, conservative measures are unlikely to provide sufficient relief or halt disease progression effectively. *Arthroscopic washing* - **Arthroscopic lavage** and debridement are rarely recommended for osteoarthritis as they have not shown sustained benefits for pain or function. - It is sometimes used for specific mechanical symptoms, but it does not address the underlying cartilage loss and structural damage in severe osteoarthritis. *Partial knee replacement* - A **partial knee replacement** is suitable when osteoarthritis is confined to a single compartment of the knee, and the other compartments are healthy. - Given the indication of "grade III osteoarthritic changes" without specifying a single compartment, a total knee replacement is generally more appropriate for widespread disease.
Question 6: A drug that is effective for rheumatoid arthritis but is not appropriate for osteoarthritis is :
- A. Infliximab (Correct Answer)
- B. Rofecoxib
- C. Acetaminophen
- D. Ketorolac
Explanation: ***Infliximab*** - **Infliximab** is a **biologic disease-modifying antirheumatic drug (DMARD)**, specifically a TNF-alpha inhibitor, used to treat **autoimmune inflammatory conditions** like rheumatoid arthritis. - Its mechanism involves modulating the immune system to reduce inflammation, which is not applicable to the **degenerative process** seen in osteoarthritis. *Rofecoxib* - **Rofecoxib** was a **COX-2 selective NSAID** used for pain and inflammation in both rheumatoid arthritis and osteoarthritis. - It was withdrawn from the market due to increased cardiovascular risk, but its initial indication covered both conditions for symptomatic relief. *Acetaminophen* - **Acetaminophen** (paracetamol) is an **analgesic** and **antipyretic** primarily used for pain relief in both osteoarthritis and rheumatoid arthritis. - It does not have significant anti-inflammatory properties and therefore is not a disease-modifying agent for rheumatoid arthritis. *Ketorolac* - **Ketorolac** is a potent **non-selective NSAID** commonly used for **acute pain** of moderate to severe intensity. - It provides symptomatic relief for pain and inflammation in both osteoarthritis and rheumatoid arthritis but does not alter the disease course in either condition.
Question 7: Mrs. Katson, a 64-year-old obese woman with bilateral knee osteoarthritis, describes pain on most days and limiting pain at least 2 days per week. She has tried activity modification (walking less) without success. All of the following therapies have been shown to be efficacious EXCEPT:
- A. Glucosamine-chondroitin (Correct Answer)
- B. Glucocorticoid steroid intra-articular injections
- C. Acetaminophen
- D. Total joint arthroplasty
Explanation: ***Glucosamine-chondroitin*** - While widely used and marketed for osteoarthritis, numerous **large, well-designed clinical trials** have consistently shown that **glucosamine-chondroitin supplements** are **not more effective than placebo** in alleviating pain or improving function in osteoarthritis. - The American College of Rheumatology (ACR) and other major medical organizations **do not recommend** its use due to a lack of evidence of efficacy. *Glucocorticoid steroid intra-articular injections* - **Intra-articular corticosteroid injections** provide **short-term pain relief** [1] and reduce inflammation in patients with osteoarthritis, especially during flares. - They are a commonly used and effective treatment for **symptomatic knee osteoarthritis** [1], although repeated injections have potential risks and may not alter long-term disease progression. *Acetaminophen* - **Acetaminophen (paracetamol)** is often recommended as a **first-line oral analgesic** for mild to moderate pain in osteoarthritis due to its relatively favorable side effect profile compared to NSAIDs for long-term use. - It works by **inhibiting prostaglandin synthesis** primarily in the central nervous system, reducing pain perception. *Total joint arthroplasty* - **Total joint arthroplasty (TJA)**, particularly **total knee replacement**, is a highly effective surgical treatment for patients with **severe, end-stage osteoarthritis** [1] who have failed conservative therapies. - It significantly **reduces pain and improves functional outcomes** [1] and quality of life for the vast majority of patients.
Question 8: Primary osteoarthritis affects all except:
- A. Metacarpophalangeal joint (Correct Answer)
- B. Hip Joint
- C. Distal interphalangeal joint
- D. Knee joint
Explanation: ***Metacarpophalangeal joint*** - The **metacarpophalangeal (MCP) joints** are typically spared in primary osteoarthritis, making their involvement a less common presentation. - Involvement of the MCP joints, particularly with significant inflammation, might suggest other conditions like **rheumatoid arthritis**. *Hip Joint* - The hip joint is a common site for primary osteoarthritis due to its **weight-bearing function** and susceptibility to mechanical stress. - Patients often experience **groin pain** and reduced range of motion, particularly internal rotation. *Distal interphalangeal joint* - The **distal interphalangeal (DIP) joints** are very commonly affected in primary osteoarthritis, leading to the formation of **Heberden's nodes**. - These nodes are bony enlargements that indicate osteophyte formation and cartilage loss. *Knee joint* - The knee joint is another frequently affected large joint in primary osteoarthritis, often presenting with **pain**, **stiffness**, and **crepitus**. - Its **weight-bearing role** contributes significantly to its vulnerability to degenerative changes.
Question 9: Osteoarthritis is typically not seen in which of the following joints?
- A. Ankle joints (Correct Answer)
- B. Knee joints
- C. Hip joints
- D. First metacarpophalangeal joint
Explanation: **Explanation:** Primary **Osteoarthritis (OA)** is a degenerative joint disease that characteristically affects weight-bearing joints and specific small joints of the hand. **Why Ankle Joints are the Correct Answer:** The **ankle (talocrural) joint** is remarkably resistant to primary osteoarthritis. This is due to the unique properties of ankle cartilage, which is thinner but has higher proteoglycan density and lower water content compared to the knee or hip, making it more resistant to compressive forces. While the ankle is a weight-bearing joint, OA here is almost always **secondary** (e.g., following intra-articular fractures, ligamentous instability, or rheumatoid arthritis) rather than primary/idiopathic. **Analysis of Incorrect Options:** * **Knee Joints:** The most common site for primary OA. It typically involves the medial compartment due to the mechanical axis of the lower limb. * **Hip Joints:** A major weight-bearing joint frequently affected by primary OA, often leading to total hip arthroplasty in elderly patients. * **First Metacarpophalangeal (MCP) Joint:** While OA commonly affects the **First Carpometacarpal (CMC)** joint (base of the thumb) and the **Distal Interphalangeal (DIP)** joints (Heberden’s nodes), the first MCP joint is also a recognized site for degenerative changes due to the high stresses of pinch and grip. **High-Yield Clinical Pearls for NEET-PG:** * **Nodal Distribution:** OA typically affects DIP joints (Heberden’s nodes) and PIP joints (Bouchard’s nodes). **MCP joints (except the 1st) and wrists are usually spared** (if involved, think Rheumatoid Arthritis). * **Radiological Hallmarks:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophyte formation. * **Kellgren-Lawrence Grading:** The standard radiological classification system for OA severity. * **Eburnation:** A pathological feature where subchondral bone becomes polished and ivory-like due to complete loss of overlying cartilage.
Question 10: Frieberg's disease involves which of the following?
- A. Tibial tuberosity
- B. Calcaneal tuberosity
- C. 2nd metatarsal (Correct Answer)
- D. 5th metatarsal
Explanation: **Explanation:** **Freiberg’s disease** is an **osteochondrosis** (avascular necrosis) affecting the head of the metatarsal. It most commonly involves the **2nd metatarsal head (Option C)** because it is the longest and most rigid metatarsal, making it susceptible to repetitive microtrauma and excessive loading during the toe-off phase of gait. It is typically seen in adolescent girls and presents with pain, swelling, and limited range of motion at the metatarsophalangeal joint. **Analysis of Incorrect Options:** * **Option A (Tibial tuberosity):** This is the site for **Osgood-Schlatter disease**, a traction apophysitis caused by repetitive strain from the patellar tendon. * **Option B (Calcaneal tuberosity):** This is the site for **Sever’s disease**, an apophysitis of the calcaneus common in active children. * **Option D (5th metatarsal):** The base of the 5th metatarsal is the site for **Iselin’s disease** (apophysitis). While the 5th metatarsal is also prone to Jones fractures, it is not the classic site for Freiberg’s. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in adolescent females (ratio ~3:1). * **Radiology:** Early stages show flattening and sclerosis of the metatarsal head; late stages show joint space narrowing and secondary osteoarthritis. * **Hierarchy of Involvement:** 2nd Metatarsal (most common) > 3rd Metatarsal > 4th Metatarsal. * **Management:** Conservative (activity modification, orthotics) is first-line; surgery (debridement or osteotomy) is reserved for refractory cases.
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