Handling Osteoarthritis: The Most Common Arthritis

Transcription

1 Handling Osteoarthritis: The Most Common Arthritis Dr. Philip A. Baer Seacourses Asia CME December 2017

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 And now, my mother will put you to sleep with tales of her arthritis.

4 Learning Objectives 1. Discuss OA pain in the context of new understanding regarding OA as an illness. 2. Review recent guidelines for OA pain management, focusing on ACR 2012 guidelines. 3. Outline evidence supporting a variety of nonpharmacologic and pharmacologic interventions for OA pain.

5 OA Case: Mr. L. O. Cal 64 yr old retired school teacher BMI - 26 Diagnosed with unilateral knee OA 3 yrs ago Past few months: pain is getting progressively worse Problems dancing and golfing

6 OA Case: Mrs. D. I. F. Fuse 70 yr old retired school teacher BMI - 30 Has pain in both knees, hips, hands, neck and low back Past few months: pain is getting progressively worse Also notes poor sleep, depressed mood Difficulty dressing, walking around house, going up and down stairs

7 Osteoarthritis in Canada OA affects1 in 8 Canadians (~4.4 Million Canadians ) ~52% of all new cases of OA occurred among Canadians < 60 years old. ~ 50% of OA patients treated with prescription medication Sources: THE IMPACT OF ARTHRITIS IN CANADA: TODAY AND OVER THE NEXT 30 YEARS. Copyright 2011 Arthritis Alliance of Canada Publication date: October 27, 2011

8 Calculated Projections for Arthritis Prevalence in Canada 2 The prevalence of arthritis is projected to increase by nearly 1 percentage point EVERY five years over the next quarter century - ultimately affecting 6.7 million Canadians age 15 and older % 18.5% 16.7% % Source: Arthritis Community Research and Evaluation Unit using Canadian Community Health Survey, , Statistics Canada. 2 Life with Arthritis in Canada: A personal and public health challenge. Public Health Agency of Canada, The Arthritis Society, etc

9 Deweber K et al. Knuckle cracking and hand osteoarthritis. J Am Board Fam Med. 2011;24(2): Is habitual knuckle cracking a risk factor for hand osteoarthritis (OA)? 188 patients with hand OA vs 141 controls Radiographic reports were reviewed to categorize which hand and which finger joints were affected with OA. Patients were asked to recall and specify which joints they regularly crack, or cracked in the past, and how often. No significant association was found between the total amount or duration of knuckle cracking and a diagnosis of OA.

10 Knuckle Cracking: Good News Simultaneously recorded audio and ultrasound imaging from 40 people: 30 habitual knuckle crackers and 10 who were not. Orthopedists blinded to the participants' knuckle-cracking history evaluated the participants for grip strength, range of motion and laxity of each MPJ both before and after the ultrasound examination. Findings: the cracking sound and bright flash on ultrasound are related to the dynamic changes in pressure associated with a gas bubble in the joint. No disability, pain or deformity was associated with knuckle cracking. December 2015 abstract: Radiological Society of North America

11 Features of Osteoarthritis (OA) Clinical presentation Pain in the joints of hands, knees, hips, and spine Joint deformity and swelling Brief morning stiffness (<30 min) Crepitus Typically worsens with time Sarzi-Puttini et al. Semin Arthritis Rheum 2005;35(1):1-10. Adapted from: Wieland et al. Nat Rev Drug Discov 2005;4(4):331-44

12 OA Anatomic Changes

13 Functional Impairment in OA Limitations in movement are very common Restricted mobility - OA of large joints Restricted range of motion - OA of small and large joints OA accounts for greater loss of independence than any other disease, especially in the elderly ~25% of patients cannot perform main activities of daily life About 25% of the visits to primary care physicians due to OA Wieland et al. Nat Rev Drug Discov 2005;4(4): Bello et al. Curr Med Res and Opinion 2006;22(11):

14 Diagnose Knee Osteoarthritis in 4 Minutes Consistent/intermittent discomfort or pain in their knee(s) ASK 4 questions: 1. at any time on most days of the month? 2. in the past year? 3. worse with activity? 4. relieved with rest? ASSESS 3 signs: 1. Effusion 2. Flexion contracture 3. Gait abnormality Minimum 1 of 3 Instructional video on the diagnosis of knee OA in 4 min (with Dr Jolanda Cibere and Leslie Neilson) Cibere et al. Association of Clinical Findings With Pre Radiographic and Radiographic Knee Osteoarthritis in a Population-Based Study. Arthritis Rheum 2010;62(12):

15 Weight-bearing X-rays are Useful in OA Diagnosis Non weight-bearing Weight-bearing

16 Pain and Radiographic Severity in Osteoarthritis Pain and functional impact poorly correlated with radiographic severity 1 Pain better predictor of disability than radiographic grade 2 1. Sarzi-Puttini et al. Semin Arthritis Rheum 2005;35(1): Salaffi et al. Clin Rheum 2005;24(1): Adapted from: Wieland et al. Nat Rev Drug Discov 2005;4(4):

17 OA Treatment Goals Treatment of OA of the knee and hip is directed towards: Reducing joint pain and stiffness Maintaining and improving joint mobility Reducing physical disability and handicap Improving health-related quality of life Limiting the progression of joint damage Educating patients about the nature of the disorder and its management Adapted from Zhang W, et al. OARSI recommendations for the management of hip and knee osteoarthritis. Part II: OARSI evidence-based, expert consensus guidelines, Osteoarthritis Cartilage

18 Osteoarthritis Pain Pain is the malady not osteoarthritis Pain drives osteoarthritis treatment Hadler NM. Knee pain Is the malady-not osteoarthritis. Ann Int Med. 1992;116(7): Moskowitz RW. Osteoarthritis, quo vadis. The Rheumatologist 2008;2(3):

19 Pain Processing in OA: The Old View The old story was wear and tear Physiology Pain Cartilage Ligaments/bone marrow Inflammation Loading/forces

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21 Pain Pathways and Neurotransmitters More Pain Substance P Glutamate and EAA Serotonin (5HT 2a, 3a ) Nerve Growth Factor Less Pain Norepinephrine Serotonin (5HT 1a,b ) Dopamine Opioids GABA Cannabinoids Adenosine Phillips, K and Clauw, D Best Practice & Research Clinical Rheumatology 25 (2011)

22 OA Guidelines

23 Ann Rheum Dis February 2013 Vol. 72 No 2

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25 ACR OA Guidelines Authors University of Maryland School of Medicine, Baltimore Marc C. Hochberg, MD, MPH David Geffen School of Medicine, University of California, Los Angeles Roy D. Altman, MD University of Ottawa School of Medicine, Ottawa, Ontario, Canada Karine Toupin April, OT, PhD - Maria Benkhalti, MSc Jessie McGowan, PhD - Vivian Welch, MSc George Wells, MD - Peter Tugwell, MD, MSc McMaster University School of Medicine, Hamilton, Ontario, Canada Gordon Guyatt, MD Queen s University School of Medicine, Kingston, Ontario, Canada. Tanveer Towheed, MD, MSc Hochberg et al, Arthritis Care & Research 2012;64( 4):

26 OA Treatment Options Non-pharmacologic treatments Pharmacotherapy

27 ACR 2012 OA Guidelines: Knee OA Nonpharmacological Strongly recommend Conditionally recommend Participate in cardiovascular (aerobic) and/or resistance landbased exercise Participate in aquatic exercise Lose weight (for persons who are overweight) Hochberg et al, Arthritis Care & Research 2012;64( 4):

28 ACR 2012 OA Guidelines: Knee OA Nonpharmacological Strongly recommend Participate in cardiovascular (aerobic) and/or resistance landbased exercise Participate in aquatic exercise Lose weight (for persons who are overweight) Conditionally recommend Participate in self-management programs Receive manual therapy in combination with supervised exercise Receive psychosocial interventions Use medially directed patellar taping Wear medially wedged insoles if they have lateral compartment OA Be instructed in the use of thermal agents Receive walking aids, as needed Participate in tai chi programs Be treated with traditional Chinese acupuncture Be instructed in the use of transcutaneous electrical stimulation Hochberg et al, Arthritis Care & Research 2012;64( 4):

29 10 lb of weight loss 48,000 less lb of pressure for every mile walked 1 = 4 1 lb of weight loss 4 lb reduction in knee joint load Messier et al. Arth. & Rheum. 2005;52(7):

30 Exercise: Core Treatment Exercise should be a core treatment for people with osteoarthritis, irrespective of age, comorbidity, pain severity or disability. Exercise should include: Local muscle strengthening General aerobic fitness. NICE = National Institute for Health and Clinical Excellence PG Conaghan, J Dickson, RL Grant BMJ 2008;336:

31 The Arthritis, Diet, and Activity Promotion Trial WOMAC Physical Function Healthy lifestyle, n= 78 Exercise only, n= 80 Weight Loss Diet only, n= % WOMAC Physical Function Improvement Diet & Exercise, n= % Average Body Weight Loss Messier et al. Arthritis & Rheumatism 2004;50(5):pp

32 Proper use of a cane Comes to wrist crease Use opposite side to affected joint OA: osteoarthritis.

33 ACR 2012 OA Guidelines: Knee OA Base Case An adult with symptomatic knee OA without comorbidities. Has not had an adequate response to OTCs Pharmacological Conditionally recommend Acetaminophen Oral NSAIDs Topical NSAIDs Conditionally recommend that patients should NOT use the following Chondroitin sulfate Glucosamine Topical capsaicin Hochberg et al, Arthritis Care & Research 2012;64( 4):

34 Acetaminophen - suggested dose ceilings Short-term use in healthy patients Chronically in healthy patient Chronically in at-risk patients* 4.0 g/day 3.2 g/day 2.6 g/day *Daily alcohol consumption, warfarin, fasting, a low protein diet, cardiac or renal disease increase the risk of hepatotoxicity. 34 Garcia Rodriguez and Hernandez-Diaz. Arthritis Res. 2001;3:

35 Efficacy Equivalence in Knee OA: Topical Diclofenac vs. Oral Diclofenac Topical (N=237) Oral (N=255) Mean change WOMAC subscales and Patient Global Assessment scores Pain SD= SD= Physical Function Topical (N=237) SD= Oral (N=255) SD= Patient Global Assessment Topical (N=234) SD= Oral (N=251) SD= Tugwell P et al. J Rheumatol Oct;31(10):

36 NSAIDs: Balancing Efficacy and Safety Antiinflammatory activity Analgesia Efficacy N S A I D S GI Tolerability GI Safety Cardiovascular Renal Safety

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38 2012 ACR Pharmacologic Recommendations: CV Protection Subgroup Patients taking low-dose aspirin ( 325 mg/d) for cardioprotection Recommendation Use nonselective NSAID other than ibuprofen + PPI COX-2 should not be used In the clinical scenario where the patient with OA is taking low-dose aspirin ( 325 mg/d) for cardioprotection and the practitioners chooses to use an oral NSAID, the panel strongly recommends...that a COX-2 selective inhibitor should not be used. Hochberg et al. Arthritis Care Res 2012; 64:

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41 NSAIDs/COXIBs and GFR GFR >60 ml/min Okay to use GFR ml/min Use with caution and careful monitoring Weight Blood pressure Electrolytes Creatinine, egfr GFR <30 ml/min Don t use COXIB: cyclo-oxygenase-2 selective inhibitor; e: estimated; GFR: glomerular filtration rate;

42 2012 ACR Pharmacologic Recommendations: GI Protection Subgroup Age >75 years History of upper GI ulcer but no bleed in past year History of upper GI ulcer with bleed in past year Recommendation Use topical rather than oral NSAIDs COX-2 or NSAID + PPI COX-2 + PPI Whenever an NSAID is used for the chronic management of patients with knee or hip OA... Consider adding a PPI to reduce the risk of development of symptomatic or complicated upper GI events. Hochberg et al. Arthritis Care Res 2012; 64:

43 Canadian Association of Gastroenterology Consensus Guidelines: Balancing GI & CV Risk Patient requires NSAID HIGH GI Risk LOW GI Risk HIGH CV Risk (on ASA) LOW CV Risk HIGH CV Risk (on ASA) LOW CV Risk Avoid NSAID if Possible Can t Avoid NSAID COX-2 Alone or tnsaid + PPI** Naproxen + PPI tnsaid Very High CV Risk Primary Concern Naproxen + PPI Very High GI Risk Primary Concern COX-2 + PPI tnsaid = traditional NSAID; COX-2 = COX-2 inhibitor; PPI = proton pump inhibitor **In high risk patients, a COX-2 inhibitor and NSAID + PPI show similar reductions of rebleeding rates, but these reductions may be incomplete Most patients on ASA + naproxen would need a PPI, except in some patients at very low GI risk Rostom A, et al. Aliment Pharmacol Ther. 2009;29(5):

44 Glucosamine A building block for articular cartilage s extracellular matrix Used to produce glycosaminoglycans (GAGs) and proteoglycans Synthesized by chondrocytes 90% absorption by oral administration 26% available for processing by the body s tissues

45 Pharmacologic Grade Glucosamine Sulphate vs. Placebo: WOMAC at Three Years (ITT) Total pain scale = 500 Total function scale = 1,700 Reginster JY et al. Lancet 2001;357:251-6.

46 OA: Complementary Therapies NIH GAIT Study NULL STUDY Glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with OA of the knee. Clegg DO et al. NEJM 2006; 354:

47 Supplements: Caveat Emptor DNA testing, performed as part of an ongoing investigation by the N.Y. Attorney General s Office, shows that, overall, just 21% of the test results from store brand herbal supplements verified DNA from the plants listed on the products labels with 79% coming up empty for DNA related to the labeled content or verifying contamination with other plant material. An important study conducted by the University of Guelph in 2013 also found contamination and substitution in herbal products in most of the products tested. As was said at the time by a spokesperson for the University of Guelph, The industry suffers from unethical activities by some manufacturers. New York Times Feb. 3, 2015

48 ACR 2012 OA Guidelines: Knee OA Clinical Scenario #2 Pharmacological If the patient does not have a satisfactory clinical response to full-dose acetaminophen (4 g) Strongly recommend Oral or Topical NSAIDs Intraarticular corticosteroid injections Conditionally recommend Tramadol Duloxetine Intraarticular hyaluronan injections Hochberg et al, Arthritis Care & Research 2012;64( 4):

49 Intra-Articular Steroids Efficacy 1-3+ months Doses of mg methylprednisolone acetate No more than 3-4 times/year in a single joint Animal studies: reduce disease progression due to inhibition of cartilage destroying enzymes Concern re atrophy of bone, soft tissues: not seen with appropriate dosing

50 Hyaluronic Acid MW 700,000 Hylan G-F 20 MW 6 million

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52 Hyaluronic Acid vs. Corticosteroids in Knee OA Time Points (weeks) Relative effect size at each time point(95% confidence intervals) Bannuru et al. Arthritis Care & Research 2009; 61(12):

53 Intra-articular Injection Sites: Knee

54 VAS Pain Intensity (mm) CR Tramadol vs. SR Diclofenac in OA CR Tramadol SR Diclofenac Baseline Duration of Treatment (weeks) There was no difference in the overall VAS pain intensity or the WOMAC pain subscale between the two groups There was no difference between treatments in physical function and joint stiffness (measured by WOMAC subscales). Pain Res Manage (2) André D. Beaulieu, Paul M. Peloso, et al.

55 Duloxetine for OA Approved for treatment of OA knee pain in Canada in July 2012 Starting dose 30 mg/day Usual dose 60 mg/day Taken with food once daily (breakfast/lunch) Can be used alone or as add-on to NSAIDs

56 Percentage of Patients Duloxetine in Knee OA Patients with 50% Reduction in Average Pain Severity Duloxetine Placebo Duloxetine vs Placebo Duloxetine vs Placebo Pooled NSAID plus Duloxetine vs Placebo Chappell et al. Pain Pract 2011;11(1): Chappell et al. Pain 2009;146(3): Frakes et al. Curr Med Res Opin 2011;27(12): Citrome & Weiss-Citrome Postgrad. Med. 2012; 124(1):

57 Alternative therapies for OA A 72 year old woman with bilateral knee osteoarthritis was admitted to hospital for a total knee replacement. Postoperatively we saw her on the ward with the outer leaf of a cabbage taped to her non-operated knee. She said that this was the only measure that provided relief from the symptoms of her osteoarthritis and that the outer cabbage leaves fitted well with the shape of her knee. BMJ VOLUME 326; 21 JUNE 2003

58 Lauche R, Graf N, Cramer H, et al. Efficacy of Cabbage Leaf Wraps in the Treatment of Symptomatic Osteoarthritis of the Knee: A Randomized Controlled Trial. Clin J Pain Nov;32(11): (Original) PMID: Effects of cabbage leaf wraps (CLWs) in the treatment of symptomatic OA. Patients with OA of the knee at stages II to III (Kellgren- Lawrence) were randomly assigned to 4 weeks of treatment with CLWs (daily for at least 2h), topical pain gel (TPG) (10 mg diclofenac/g, at least once daily), or usual care (UC). CLWs are more effective for knee OA than UC, but not compared with diclofenac gel. Therefore, they might be recommended for patients with OA of the knee. Further research is warranted. At first, I thought this might be an April Fools Day article. But, I learned something new.

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60 Urinating in the Standing Position: A Feasible Alternative for Elderly Women With Knee OA We recruited 21 women with a mean age of 65.0 years who had knee OA and were unable to maintain or found it difficult to stand up from a squat or crouch. Urinating while standing is a feasible option for elderly women with knee osteoarthritis who have difficulty crouching or squatting to void in public restrooms. Chou E at al. The Journal of Urology Volume 186, Issue 3, September 2011, Pages

61 GoGirl website

62 ACR 2012 OA Guidelines: Knee OA Clinical Scenario #3 If the patient does not have an adequate response to both nonpharmacologic and pharmacologic modalities and is either unwilling to undergo or is not a candidate for total joint arthroplasty Pharmacological Strongly recommend Opioid analgesics Follow the recommendations of the APS/AAPM for the use of opioid analgesics in the management of chronic noncancer pain Conditionally recommend Duloxetine Traditional Chinese acupuncture Transcutaneous electrical stimulation Hochberg et al, Arthritis Care & Research 2012;64( 4):

63 Bottom line No research demonstrates long-term improvement in OA pain or function with opioids. In elderly patients, it is unclear if opioids or NSAIDs are safer. Opioids should not be routinely used in OA but, if they are necessary, use them with caution and monitor carefully.

64 What if Nothing Works? 77 y.o. Ailing Ontario woman Inflammatory and erosive OA Incurable, debilitating illness and declining health In constant, intolerable pain despite every effort of my physicians to manage it Intolerable suffering I will remain here in this room forever, in pain, until someone allows me to die. I have no future. Toronto Star June 19, 2017; Globe and Mail June 20, 2017

65 What if Nothing Works? 77 y.o. Ailing Ontario woman Under Bill C-14, adult patients can receive medical assistance in dying (MAID) if they meet four criteria: Having a serious and incurable illness or disability Being in an advanced state of irreversible decline Enduring intolerable pain Facing a reasonably foreseeable death Toronto Star June 19, 2017; Globe and Mail June 20, 2017

66 What if Nothing Works? 77 y.o. Ailing Ontario woman In a decision delivered on June 19, 2017, in Toronto, Superior Court Justice Paul Perell declared that the applicant s natural death is reasonably foreseeable, noting that the doctor had reached the same conclusion but later changed his mind because he feared he could be prosecuted. Toronto Star June 19, 2017; Globe and Mail June 20, 2017

67 What if Nothing Works? 77 y.o. Ailing Ontario woman Aug. 10, 2017: AB has died with medical assistance. She had severe osteoarthritis but her doctor would not perform the end-of-life procedure because he was concerned she did not meet the reasonable foreseeable death requirement. In a ruling in June, Superior Court Justice Paul Perell said that a person does not need to have a terminal condition or be likely to die within a specific time frame to access medical assistance in dying. After AB died, her daughter said it was the first time in decades that she had seen her mother in a pain-free state, the release said. Toronto Star June 19, 2017 and Aug. 10, 2017; Globe and Mail June 20, 2017

68 ACR Osteoarthritis Guideline: Number Needed to Treat for Pain Hochberg et al. Arthritis Care Res, 64:

69 FDA fast-tracks Lilly/Pfizer pain drug amid opioid crisis OA: Is Anything New Coming? FDA fast-tracks Lilly/Pfizer pain drug amid opioid crisis (June 15, 2017) The US regulator granted tanezumab a fast track designation for patients with osteoarthritis and chronic low back pain. The phase 3 programme is ongoing and includes six studies in 7,000 patients with osteoarthritis, chronic lower back pain, or cancer pain, who do not experience adequate pain relief with approved therapies and results are due next year. The anti-nerve growth factor (NGF) inhibitor was delayed for years because of safety fears that emerged during animal studies.

70 OA Surgery

71 Arthroscopy for Knee OA: Not Recommended

72 Arthroscopy for Knee OA: Not Recommended

73 Arthroscopy for Knee OA: Not Recommended

74 Adjunct to Core Therapy: Referral Criteria for Surgery Referral for joint replacement surgery should be considered for people with osteoarthritis who experience joint symptoms that have a substantial impact on their quality of life and are refractory to non-surgical treatment. Referral should be made before there is prolonged and established function limitation and severe pain. Total joint Arthroplasty Hemi-arthroplasty NICE Guidelines PG Conaghan, J Dickson, RL Grant BMJ 2008;336:

75 OA Surgery TKR TKR = Total Knee Replacement

76 CIHI 2012 Cost of THR/TKR $100 million increase in costs over 2 years Wait Times for Priority Procedures, 2013-released March 19, 2013

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78 RCT of TKR NEJM 2015

79 RCT of TKR NEJM 2015

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81 Knee replacement may go poorly for people who think life isn't fair People who tend to blame others for their suffering and think setbacks in their lives are irreparable tend to report more pain after knee replacement surgery, according to a new study. This is not the first time feelings of personal injustice have been tied to longer recovery times and increased disability after injury.

82 ACR 2012 OA Guidelines: Knee OA Pharmacological Treatment Summary IF there is an inadequate response to intermittent use of OTC acetaminophen, OTC NSAIDs or OTC nutritional supplements. IF there is an inadequate response to full-dose acetaminophen (4 g). IF there is an inadequate response to both non-pharmacologic and pharmacologic treatments and total joint arthroplasty is not an option. Acetaminophen Oral NSAIDs Topical NSAIDs Tramadol IA corticosteroid Oral or Topical NSAIDs IA corticosteroid Opioid analgesics Do not use the following Chondroitin sulfate Glucosamine Topical capsaicin Tramadol Duloxetine IA hyaluronan Duloxetine Acupuncture TENS = Strongly Recommend = Conditionally Recommend IA Intraarticular, TENS Transcutaneous electrical stimulation Hochberg et al, Arthritis Care & Research 2012;64(4):

83 Resources

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86 AAC CFPC CEP OA Tool

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90 Assessment and Screening HAQ HAQ-II MDHAQ Referral Tool (CART) Counselling Osteoarthritis Rx NSAIDS and OA Educational Resources Elbow Examination Follow-Up Patient Assessment Hip Examination New Patient Assessment

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93 PEARLs: OA Use non-pharmacologic therapy in all patients Adapt therapy to patient comorbidities and patient preference Avoid therapies with little evidence (glucosamine, chondroitin, other supplements, Botox, acupuncture, PRP) Joint replacement is an elective surgery

94 Barriers to Change: OA Limited access to non-pharmacologic therapies Weight loss very effective but very difficult to achieve Over-reliance on NSAIDs Too many unnecessary MRIs and arthroscopies performed

95 Questions?