Orthopedics Case No 3. Osteoarthritis-1

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Orthopedics Case No 3. Osteoarthritis-1

হাঁটুর অস্টিওআর্থাইটিসের চিকিৎসা।

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সার্জারি ছাড়া অন্যান্য অপশান গুলো নিয়ে বলব।

প্রথমে বলব কি কি চিকিৎসা দিবেন না। কোন ভূমিকা প্রমানিত নয়।

> ক্যালসিয়াম

> ভিটামিন ডি।

> ভিটামিন বি১,৬,১২ (নিউরো-বি)

> ওরাল সায়ালক্স (হায়ালুরোনেট)

> ইন্ট্রা আরটিকুলার হায়ালুরোনেট (NICE গাইডলাইন মতে)।

> জয়েন্ট লেভেজ।

> ওরাল গ্লুকোসামাইন।

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এখন আসি কি কি দেয়া যায়? চিকিৎসা একটু ফ্রাস্টেটিং।

চিকিৎসার উদ্দেশ্য ব্যথা কমানো, মবিলাইজ করা, ফাংশান ইমপ্রুভ করা ও সর্বোপরি কোয়ালিটি অব লাইফ ইমপ্রুভ করা। রোগ ভাল করা নয়। আবার বলছি, রোগ ভাল হবে না। সব চিকিৎসা সাময়িক ব্যথা কমাবে মাত্র। এই ম্যাসেজ আগেই রোগিকে দিয়ে দিতে হবে।

মনে রাখতে হবে, “এই রোগে কোন ম্যাজিক নাই”। তাই এর খোঁজে রোগি যেন “ডক্টর শপিং” না করে।

নন-ফার্মাকোলজিক।

“””””””””””””””””””””””””””””””

স্ট্রং এভিডেন্স:

““““““““`

১) ওজন কমানো (যাদের বেশি)। ১০% কমাতে পারলে ভাল। ১ পাউন্ড ওজন কমালে হাটুর উপর ৪ পাউন্ড ওজন কমবে।

২) এরোবিকস। খুবই জরুরি।

রোগিরা প্রায় বলে, ব্যথার জন্য হাটতে পারি না। তাদের বলতে হবে, অল্প অল্প হাটেন। ব্যথা ধীরে ধীরে কমে আসবে। সুইমিং একটা ভাল বিকল্প, যাদের সুবিধা আছে।

৩) ব্যালান্স ট্রেনিং। তাই ছি (Tai Chi) বেস্ট৷ তবে এটার ট্রেনার কম। ইয়োগা, পাইলেটস।

উইক এভিডেন্স:

“““““““““`

১) হিট থেরাপি। হট ব্যাগে বার্ণ হয়৷ কুসুম গরম পানিতে ভিজা কাপড়ের সেঁক দেয়া বেটার। অথবা ডীপ হিট (আলট্রাসাউন্ড, শর্ট ওয়েভ)। এগুলো সাময়িক ব্যথা কমায়। তবে সাইড এফেক্ট নাই।

২) মিডিয়াল/ লেটারাল ওয়েজ (wedge) বা ইনসোল। সবার জন্য নয়। যাদের বায়োমেকানিক্স এ প্রবলেম।

৩) নী- সাপোর্ট। হাঁটার সময় দিবেন। সারাদিন দিলে পায়ে পানি আসবে।

৪) ইলেক্ট্রো থেরাপি, আকুপাংচার, ম্যানিপুলেশন: এগুলোর তেমন এভিডেন্স পাওয়া যায়নি। তাই অনেক টাকা নিলে দেয়া অনুচিত। তবে এগুলো প্রায় হার্মলেস।

৫) ওয়াকিং এইড: ক্রাচ, স্টিক, ওয়াকার। এডভান্সড স্টেজে।

ফার্মাকোলজিক। Drug Managment:-

“”””””””'”‘””””'””””””””””

১) প্যারাসিটামল। কিছু ব্যথা কমায় স্টেজ ৩ পর্যন্ত। কন্টিনিউয়াস দেয়া যাবে না।

২) NSAIDs. এফেক্টিভ। তবে শর্ট কোর্স। লোয়েস্ট পসিবল ডোজ।

Tablet:Flexi SR 200 mg (As a Aceclofenac As a Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs).)

Indications of Tablet:Flexi SR 200 mg (As a Aceclofenac As a Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs).)

Flexi SR is indicated for the relief of pain and inflammation in osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, toothache, trauma and lumbago.

Pharmacology Tablet:Flexi SR 200 mg (As a Aceclofenac As a Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs).)

Aceclofenac is a non-steroidal drug with anti-inflammatory and analgesic properties. It is a potent inhibitor of the enzyme cyclooxygenase, which is involved in the production of prostaglandin. After oral administration, it is rapidly and completely absorbed an unchanged drug.

Side Effects Tablet:Flexi SR 200 mg (As a Aceclofenac As a Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs).)

Flexi SR is a non-steroidal drug with anti-inflammatory and analgesic properties. It is a potent inhibitor of the enzyme cyclooxygenase, which is involved in the production of prostaglandin. After oral administration, it is rapidly and completely absorbed an unchanged drug.

৩) উইক অপিওয়েড (ট্রেমাডল)। বার বার দিতে অনুৎসাহিত করেছে।

2.Capsule:Anadol SR 100 mg( As A Tramadol Hydrochloride Opioid analgesics.)

Indications Capsule:Anadol SR 100 mg( As A Tramadol Hydrochloride Opioid analgesics.)

Anadol SR is used for the treatment of moderate to severe painful conditions. These include:

Postoperative pain
Colic and spastic pain
Cancer pain
Joint pain
Neck and back pain
Pain associated with osteoporosis.

Pharmacology Capsule:Anadol SR 100 mg( As A Tramadol Hydrochloride Opioid analgesics.)

Tramadol is a centrally acting synthetic analgesic compound. It inhibits the re uptake of neurotransmitters- serotonin and noradrenaline. Thus it modifies the transmission of pain impulses by activating both descending serotonergic pathways and noradrenergic pathways involved in analgesia. The analgesic effects of Tramadol are mediated via stimulation of mu-opioid receptors and indirect modulation of central monoaminergic inhibitory pathways.

Dosage & Administration Capsule:Anadol SR 100 mg( As A Tramadol Hydrochloride Opioid analgesics.)

Capsule or Tablet: Usual doses are 50 to 100 mg every four to six hours. For acute pain an initial dose of 100 mg is required. For chronic painful conditions an initial dose of 50 mg is recommended. Subsequent doses should be 50 to 100 mg administered 4-6 hourly. The dose level and frequency of dosing will depend on the severity of the pain.The total daily dosage by mouth should not exceed 400 mg.

Sustained Release Capsule or Tablet: One SR capsule or tablet every 12 hours, for example first one in the morning and then at the same time in the evening. The number of capsules taken at a time will depend upon severity of pain, but it should not be taken more frequently than every 12 hours.The total daily dosage by mouth should not exceed 400 mg.

Injection: A dose of 50-100 mg may be given every 4 to 6 hours by intramuscular or by intravenous infusion. For the treatment of postoperative pain,the initial dose is 100 mg followed by 50 mg every 10 to 20 minutes if necessary to a maximum of 250 mg in the first hour. Thereafter, doses are 50 to 100 mg every 4 to 6 hours up to a total daily dose of 600 mg.

Suppository: Tramadol suppository should be administered rectally. For adults usual dose is 100 mg Tramadol Hydrochloride 6 hourly. In general, 400 mg Tramadol Hydrochloride (4 Tramadol suppository) per day sufficient. However, for the treatment of Cancer pain and severe pain after operations much higher daily doses can be used.

Side Effects Capsule:Anadol SR 100 mg( As A Tramadol Hydrochloride Opioid analgesics.)

Commonly occurring side-effects are dizziness/vertigo, nausea, constipation, headache, somnolence, vomiting, pruritus, CNS stimulation, asthenia, sweating, dyspepsia, dry mouth, diarrhoea. Less commonly occurring side-effects include malaise, allergic reaction, weight loss, vasodilatation, palpitations, abdominal pain, anorexia, flatulence, GI bleeding, hepatitis, stomatitis etc.

৪) ডুলক্সিটিন। ক্রোনিক পেইনে।

Capsule:1. Diliner DR 60 mg (As a Duloxetine Hydrochloride As a Serotonin-norepinephrine reuptake inhibitor (SNRI)).

Indications of Capsule:- Diliner DR 60 mg (As a Duloxetine Hydrochloride As a Serotonin-norepinephrine reuptake inhibitor (SNRI)):-

Diliner DR is a serotonin and norepinephrine reuptake inhibitor (SNRI) indicated for-

Major Depressive Disorder (MDD)
Generalized Anxiety Disorder (GAD)
Diabetic Peripheral Neuropathic Pain (DPNP)
Fibromyalgia and
Chronic Musculoskeletal Pain.

Pharmacology of Capsule:- Diliner DR 60 mg (As a Duloxetine Hydrochloride As a Serotonin-norepinephrine reuptake inhibitor (SNRI)):-

Duloxetine Hydrochloride is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) for oral administration. Duloxetine is a less potent inhibitor of dopamine reuptake. Duloxetine has no significant affinity for dopaminergic, adrenergic, cholinergic, histaminergic, opioid, glutamate, and GABA receptors in vitro. Duloxetine does not inhibit monoamine oxidase (MAO). Orally administered Duloxetine hydrochloride is well absorbed. Elimination of Duloxetine is mainly through hepatic metabolism.

Dosage & Administration of Capsule:- Diliner DR 60 mg (As a Duloxetine Hydrochloride As a Serotonin-norepinephrine reuptake inhibitor (SNRI)):-

Major Depressive Disorder (MDD)-

Starting Dose: 40 mg/day to 60 mg/day
Target Dose: Acute: 40 mg/day (20 mg twice daily) to 60 mg/day (once daily or as 30 mg twice daily); Maintenance: 60 mg/day
Maximum Dose: 120 mg/day

Generalized Anxiety Disorder (GAD)-

Starting Dose: 60 mg/day
Target Dose: 60 mg/day (once daily)
Maximum Dose: 120 mg/day

Diabetic Peripheral Neuropathic Pain (DPNP)-

Starting Dose: 60 mg/day
Target Dose: 60 mg/day (once daily)
Maximum Dose: 60 mg/day

Fibromyalgia-

Starting Dose: 30 mg/day
Target Dose: 60 mg/day (once daily)
Maximum Dose: 60 mg/day

Chronic Musculoskeletal Pain-

Starting Dose: 30 mg/day
Target Dose: 60 mg/day (once daily)
Maximum Dose: 60 mg/day

Some patients may benefit from starting at 30 mg once daily. There is no evidence that doses greater than 60 mg/day confers an additional benefit, while some adverse reactions were observed to be dose-dependent. A gradual dose reduction is recommended to avoid discontinuation symptoms.

Side Effects of Capsule:- Diliner DR 60 mg (As a Duloxetine Hydrochloride As a Serotonin-norepinephrine reuptake inhibitor (SNRI)):-

The most commonly observed adverse events in Diliner DR treated patients were nausea, dizziness, dry mouth, constipation, decreased appetite, fatigue, somnolence, increased sweating, hyperhidrosis and asthenia. It may slightly increase blood pressure. No clinically significant differences were observed for QT, PR, and QRS intervals between Diliner DR-treated and placebo-treated patients.

Tablet : Joinix D (750mg+50mg) (As a Glucosamine sulfate+Diacerein ) As a Stimulation of Cartilage formation.

Indications of Tablet : Joinix D (750mg+50mg) (As a Glucosamine sulfate+Diacerein ) As a Stimulation of Cartilage formation:-

This tablet is indicated in-

Osteoarthritis
Rheumatoid arthritis
Bone and Joint injuries

Pharmacology of Tablet : Joinix D (750mg+50mg) (As a Glucosamine sulfate+Diacerein ) As a Stimulation of Cartilage formation:-

Glucosamine: Glucosamine (2-amino-2-deoxy-alpha-D-glucose) is a natural amino sugar, produced by the body and found in certain foods. It is the most fundamental building block required for biosynthesis of glycosaminoglycans (GAGs) like Hyaluronic Acid, Keratan Sulfate and Chondroitin Sulfate. GAGs binds with protein and form proteoglycans, the essential building block of articular cartilage. When cartilage in a joint deteriorates, Osteoarthritis develops. It also helps to form ligaments, tendon, nails and various other connective tissues. When we take artificially synthesized Glucosamine Sulfate supplement, it increases Glucosamine level in the body, thus facilitates production and repair of cartilage. Glucosamine also activates chondrocytes in the cartilage which help produce GAGs and proteoglycans.

In humans, about 90 percent of glucosamine, administered as an oral dose of glucosamine sulfate, is absorbed from the digestive tract. Predominantly metabolized by liver & excreted through urine.

Diacerein: This is used for the treatment of Osteoarthritis. It has also analgesic, antipyretic and anti-inflammatory activity. It release in vitro and directly inhibits InterLeukin-1(IL-1) synthesis, which is the main cytokine involved in cartilage destruction. Due to specific mode of action, it have been shown to have disease-modifying effect in experimental models of osteoarthritis and in human subjects with finger joint and knee osteoarthritis.

Oral bioavailability of Diacerein 56%. Concurrent intake of food delays the time to peak concentration but associated with a 25% increase in absorption. Therefore, diacerein is best given with food. Mainly binds with protein albumin. Diacerein is metabolized extensively (100%) in liver following oral dosing. Urinary excretion of diacerein in the form of its metabolites has ranged between 35% and 60%.

Dosage & Administration of Tablet : Joinix D (750mg+50mg) (As a Glucosamine sulfate+Diacerein ) As a Stimulation of Cartilage formation:-

Use in adults: One tablet twice daily with food.

Use in children and adolescents: The safety and effectiveness of children and adolescents under the age of 18 years have not been established.

Side Effects of Tablet : Joinix D (750mg+50mg) (As a Glucosamine sulfate+Diacerein ) As a Stimulation of Cartilage formation:-

No serious adverse effect has been reported. Nausea, vomiting, diarrhea, epigastria pain, headache, skin rashes & intense yellow coloring of urine may be occurred.

Tablet5:-Syalox Plus 300mg (AS A Hyaluronic Acid As a Acetyl Glucosamine and Glucuronic ) which is a natural polymer. These are the important functions in articular cartilage and synovial fluid which can help in cases of stiffness and mild knee, shoulder, hip, knee, and to improve their mobility. This tablet also consists of AKBA, 3-O-Acetil-11-Keto-β-Boswellico of Boswellia Serrata. It is a powerful anti-inflammatory which helps to reduce the swelling of the joints and improve the joint mobility..

Indications of Tablet:-Syalox Plus 300mg (AS A Hyaluronic Acid As a Acetyl Glucosamine and Glucuronic ):-

This is indicated in-

Relieve symptoms of knee osteoarthritis (OA)
Reduces Joint pain
Improves joint mobility
Reduces inflammation and swelling

Pharmacology Tablet:-Syalox Plus 300mg (AS A Hyaluronic Acid As a Acetyl Glucosamine and Glucuronic ):-

Hyaluronic Acid (HA) is a natural organic compound synthesized by fibroblasts and is composed of repeating disaccharide units formed by Glucuronic acid and N-acetylglucosamine acid. The main function of HA, in most biological processes, is to maintain the structural and functional characteristics of tissues. The biosynthesis of HA decreases with age and traumas. Boswellia (containing AKBA at 10%) is useful for the joint function.

This tablet has patented triple-coating technology with two different molecular weights of Hyaluronic acid. The purpose of the different molecular weight is to allow the higher molecular weight to be broken down by the stomach acids and the lower molecular weight to be absorbed through the synovial fluids so to ensures the ingredients will reach the joints unchanged and will not break into the stomach by the acids that are there.

This is made from Hyaluronic acid extracted from Fermented vegetables which is a 100% Vegetarian product. It has all-natural ingredients. This is a new technology. Hyaluronic acid content N-Acetyl Glucosamine and Glucuronic which is a natural polymer. These are the important functions in articular cartilage and synovial fluid which can help in cases of stiffness and mild knee, shoulder, hip, knee, and to improve their mobility. This tablet also consists of AKBA, 3-O-Acetil-11-Keto-β-Boswellico of Boswellia Serrata. It is a powerful anti-inflammatory which helps to reduce the swelling of the joints and improve the joint mobility.

This modified-release triple-layer tablet, based on high molecular weight Hyaluronic Acid and Boswellia containing AKBA at 10%, is developed with a patented process to improve the stability and bioavailability of the Formulation.

Dosage & Administration Tablet:-Syalox Plus 300mg (AS A Hyaluronic Acid As a Acetyl Glucosamine and Glucuronic ):-

Take one tablet a day, preferably before or during meals, with plenty of water.

Side Effects Tablet:-Syalox Plus 300mg (AS A Hyaluronic Acid As a Acetyl Glucosamine and Glucuronic ):-

There have been no known side effects reported so far. But if you have any specific allergies, we recommend you to consult with your doctor before taking this supplement.

৫) টপিক্যাল NSAIDs. কিছুটা এফেক্টিভ। সেইফ। দেয়া উচিৎ।

৬) টপিক্যাল ক্যাপসাইসিন। কাজ করে। বিশেষ করে ক্রোনিক পাইনে। (তবে ক্রোনিক পেইনের ফিচার গুলো জেনে নিবেন।)

Cream 1:- Topicacin 0.025% w/w 20 gm tube

(As A Capsaicin Topical Analgesics, Topical anti-inflammatory preparations).

ইন্টারভেনশন।

“”””””””””””””””””””'”

১) ইন্ট্রা আরটিকুলার স্টেরয়েড।

– একিউট ফ্লেয়ার এ।

– NSAIDs ফেইল হলে।

– ব্যথার জন্য ব্যায়াম করতে না পারলে। (NICE, ACR).

২) রেডিও ফ্রিকোয়েন্সী নার্ভ এবলেশন। উপরের সব চিকিৎসায় কাজ না হলে। অপারেশন ইন্ডিকেশন আছে কিন্তু কোন কারনে করতে না পারলে।

৩) পি.আর.পি ও স্টেম সেল (রিজেনারেটিভ)।

এখনো গাইড লাইনে আসেনি। তবে প্রমিজিং বলা হয়েছে। যথেষ্ট রিসার্চ নাই।

তবে আমার ব্যক্তিগত অভিজ্ঞতায় গ্রেড-৩ পর্যন্ত দিলে ৬০% ক্ষেত্রে কাজ করে। পেশেন্ট সিলেকশন জরুরি। ওবেসিটি থাকলে সিউর ফেল করবে।

ইন্ডিয়ান পেইন স্পেশালিষ্টরা খুব আর্লি স্টেজে দিয়ে দিচ্ছেন, যখন হয়তো আমাদের রোগিরা রাজিই হবে না। যেহেতু এফেক্টিভিটি সন্দেহজনক, তাই প্রাইস কম নেয়া উচিৎ হবে এবং রোগিকে ক্লিয়ার বলে দিতে হবে ৫০/৫০ চান্স।

আমার দেখায়, পি.আর.পি তে কাজ না হলে স্টেম সেলেও কাজ হয় না (এটা আমার অভিজ্ঞতা)। স্টেম সেল অনেক খরচ। তাই আমি প্রেফার করি কম। কারন আসলে “ম্যাজিক” তো নাই। তাহলে এত টাকা খরচ করানোর যুক্তি কি?

ধন্যবাদ।

Raiyyan Tahsan Date:-27-12-2024 Friday Time:-4-45-37 Pm.

Raiyyan Tahsan

Raiyyan Tahsan