NURS 504 LIBERTY Case Study Critique Osteoarthritis 2025.docx

Case Study Critique: Osteoarthritis 1

Case Study Critique: Osteoarthritis Micaela

Wiedlin

School of Nursing, Liberty University

CB’s case study discusses a complex clinical scenario involving multiple chronic

conditions including osteoarthritis, diabetes, and obesity. The provider, Ms. Sample, proposes a

treatment plan involving various medications for pain management, diabetes control, and

potentially a treatment for hypertension. Ms. Sample collects pertinent information that

includes CB’s medical history, comorbidities, and risk factors and considers this information in

include treatments for the disease. I would recommend that Ms. Sample completes a thorough

Case Study Critique: Osteoarthritis 2

assessment of CB’s pain to accurately diagnosis osteoarthritis and to rule out other autoimmune

disorders.

The National Institute for Health and Care Excellence established the criteria needed to

clinically diagnose OA. A clinical diagnosis of OA can be made without imaging in patients who

are 45 or over, have activity-related joint pain, and have either no morning joint-related stiffness

or morning stiffness that lasts no longer than 30 minutes (2022). Although CB’s activity-related

joint pain and age meet the criteria, Ms. Sample did not ask CB if she had experienced joint

stiffness in the morning and if so, how long it persisted for. It is important to obtain this

information because it can distinguish OA from other inflammatory diseases such as rheumatoid

arthritis, which would require a treatment plan that is slightly different.

CB has a history of a broken ankle and bone in her foot that required a cast for six weeks

osteoarthritis. I agree with her decision to recommend exercise but the initial weight loss goal

for CB should be 10% of her current body weight. Exercise should be observed in office before

sending CB home to ensure that they are being done properly and safely (Kolasinski et al.,

2019).

Case Study Critique: Osteoarthritis 3

I agree with Ms. Sample’s interpretation of CB’s elevated uric acid level that puts her at

an increased risk for gout and arthritis. A comprehensive discussion should be done detailing

the potential relationship between CB’s hyperuricemia and osteoarthritis. Research shows that

uric acid levels may be associated with the pathogenies of OA and can be important indicators

of the severity and activity of OA (Kim et al., 2020). Ms. Sample does not recommend any

pharmacological or nonpharmacological therapies that will decrease CB’s uric acid levels. Uric

acid is a potential trigger that can increaser the inflammatory response of synovial membrane in

OA (Kim et al., 2020). Ms. Sample recommends the NSAID, diclofenac, which helps with

inflammation, however, recommending a xanthine oxidase inhibitor, like allopurinol, will reduce

equation to diagnose CB. This equation cannot be used to diagnose CKD as the results are

inaccurate because it is not expressed using standardized creatinine levels and results in falsely

elevated GFR levels (National Kidney Foundation, 2023). A GFR<60ml/min/1.73m2 for more

than 3 months is part of the criteria for CKD, in addition to abnormalities of kidney structure or

function, present for >3 months (National Kidney Foundation, 2023). I do believe CB’s kidney

function should closely monitored as she has several risk factors for CKD, however, additional

Case Study Critique: Osteoarthritis 4

information is needed for the actual diagnosis of CKD such as albumin-to-creatine-ratio to

detect albuminuria.

Ms. Sample acknowledges that CB’s current medication regimen is not currently treating

her conditions. I agree with her conclusion that Tylenol is not alleviating her pain and that CB

will need a stronger NSAID in addition to combination therapy for her uncontrolled type 2

diabetes. I agree with Ms. Sample’s decision to continue CB’s prophylaxis aspirin at a dose of

81mg daily to reduce her risk of MI due to her comorbidities. I also agree with her decision to

delay treatment for hypertension at this time since CB’s pain could be a contributing factor to

CB’s blood pressure. CB should have home or ambulatory BP monitoring and a repeat office visit

to confirm blood pressure. If CB’s repeat blood pressure in office is >140/90 mm/Hg, she should

be started on an antihypertensive that is appropriate given her age and comorbidities.

caused by chronic NSAID use. Should CB require long-term used of an NSAID wile reaching goal

weight, Ms. Sample can recommend switching to a topical NSAID shown to benefit knee and hip

OA (ACR/AF, 2019). Long-term treatment with topical diclofenac sodium 1% gel has shown to be

Case Study Critique: Osteoarthritis 5

Ms. Sample should not delay the use of intraarticular glucocorticoid injections. These

injections are associated with short-term efficacy in treatment of knee OA and can be used

every three months as needed (ACR/AF, 2019). Use of these injections to alleviate CB’s pain will

make it easier for her to participate in regular exercise. One goal weight is achieved, the use of

intraarticular glucocorticoid injections could be reassessed.

Although CB is at high risk for GI bleeding due to NSAID use, the proton pump inhibitor

(PPI), Omeprazole, suggested by Ms. Sample is not appropriate for CB. Chronic PPI used

exceeding eight weeks in elderly patients increases the risk for C. difficile, decreased bone

integrity, and fractures (Burchum & Rosenthal, 2022). An alternative medication to reduce the

risk of GI bleed secondary to NSAID use that is considered safe in elderly populations would be a

recommended starting dose is 10 units of long-acting insulin per day and should be adjusted by

24 units once or twice a week to reach target fasting blood glucose in patients whose A1c

remains uncontrolled for longer than three months (Chun et al., 2019). It is important to

Case Study Critique: Osteoarthritis 6

vials. A detailed discussion with CB about the benefits and risks of the proposed combination

therapy is crucial to ensure her understanding and compliance.

I agree with Ms. Sample’s decision to increase CB’s metformin dosage in the setting of

uncontrolled type 2 diabetes; however, I disagree with Ms. Sample’s decision to change CB’s

metformin dose from extended release (ER) to immediate release (IR). Metformin ER and

metformin IR are similar in effectiveness; however, the extended-release version is associated

with improved compliance to treatment due to decreased side effects and not having to take

more than one pill a day (Tan et al., 2021). Since CB’s compliance is unknown and could

potentially be a concern, it best that she takes a 1,700 mg metformin ER tablet once daily. CB

should have her renal function closely monitored while on this medication, especially with her

current risk for kidney disease.

for CB’s type 2 diabetes combination therapy.

A GLP-1 inhibitor is recommended in patients that are overweight or obese (ADA, 2023).

This medication class is associated with a reduction in CVD and can also help with weight loss

which will alleviate pain from osteoarthritis Ozempic and liraglutide would be a better add-on

therapy for CB. Liraglutide is associated with a significant decrease in cardiovascular death but

Case Study Critique: Osteoarthritis 7

function, and support system will determine which medication is best for CB. Should CB not

reach her target A1c at her follow-up or if a GLP-1 is not tolerated due to nausea, CB should be

switched to either regimen 1 or 2 listed in the 2018 ADA’s Standards of Medical Care of

Diabetes. Regimen 1 includes the addition of rapid-acting insulin injection before the largest

meal, while regimen 2 includes changing to premixed insulin twice daily, once before breakfast

and once before dinner (ADA, 2018).

CB’s case study highlights the challenging scenario of managing multiple chronic

conditions with pharmacological interventions. Overall, the medication choices in the proposed

treatment plan for CB are generally appropriate based on the clinical presentation and current

guidelines. However, some aspects, such as the potential cardiovascular and gastrointestinal risk

of gout prophylaxis, need further consideration.

References

Burchum, J. R. & Rosenthal, L.D. (2022). Lehne’s Pharmacology for Nursing Care (11th ed.) St.

Louis, MO: Elsevier.

Posey L(Eds.), DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition. McGraw

Peniston, J. H., Gold, M. S., Wieman, M. S., & Alwine, L. K. (2012). Long-term tolerability

of topical diclofenac sodium 1% gel for osteoarthritis in seniors and patients with

comorbidities. Clinical interventions in aging, 7, 517–523.

https://www.hopkinsarthritis.org/physician-corner/education/arthritis-education-diagnostic-

guidelines/ #class_hip

Samson, S. L., Vellanki, P., Blonde, L., Christofides, E. A., Galindo, R. J., Hirsch, I. B., Isaacs, S. D., Izuora, K. E.,

Low Wang, C. C., Twining, C. L., Umpierrez, G. E., & Valencia, W. M. (2023). American association of