CARE GUIDE for Osteoarthritis

Transcription

1 CARE GUIDE for Osteoarthritis SUGGESTED Initial Evaluation: Suspected Knee Degenerative Joint Disease (DJD) (1,2) Diagnosis of osteoarthritis (OA) is mostly clinical: History and Physical point to correct diagnosis Disease is progressive and insidious (acute joint presentation is possible but not common) Physical findings Swelling due to effusion with little synovial thickening, usually with little warmth Atrophy of the surrounding muscles Restricted active and passive range of motion Crepitus Pain at the extremes of existing range of motion Joint deformity Set realistic expectations Educate patient about the natural history of OA Management may require interdisciplinary approach Immediate intervention for those presenting with: Hot, swollen joint, with or without fever and/or feeling ill Cannot bear weight on leg Leg or foot is cool and/or blue Deformity Severe pain Locked knee (unable to bend) Demands to be seen today If findings are inconclusive for DJD, further workup indicated Antero-posterior (AP), lateral & patellar films are indicated in: Trauma, significant effusion, loss of range of motion, severe pain, failed conservative treatment Further Evaluation (2,3) If atypical clinical features are present, or if age is younger than 50 years, pursue additional studies Imaging (X-Ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Ultrasound, bone scan) Laboratory studies Erythrocyte Sedimentation Rate (ESR), uric acid Rheumatoid Factor Findings may indicate need for referral to rheumatologist, orthopedic surgeon, and/or physical medicine and rehabilitation medicine specialists Coordinate followup care with specialist as needed 1

2 Joint tap and other studies as needed Gram stain and bacterial culture Crystal analysis Cell count and differential Glucose, protein, Lactate dehydrogenase (LDH) General Treatment (1,2, 4-10) Initiate conservative regimen Goals of treatment are to: Provide understanding of disease for improved selfefficacy and selfmanagement Reduce pain Instruct on exercises Improve overall functioning and safety Overall treatment should be tailored, taking into account age, co-morbidity and Nonpharmacologic Therapies Patient self-care education and local support groups (materials available through the Arthritis Foundation ( Begin peri-articular muscle strengthening exercises, particularly quadriceps muscles Cold and/or heat therapy Protective and assistive/adaptive devices Avoid prolonged kneeling, sitting, walking, climbing Weight loss, minimum of 5% of body weight, especially when Body Mass Index (BMI) 25 Exercise (5) Low impact, moderate intensity aerobic exercise (150 minutes/week), balance training, and range of motion/flexibility exercises, OR 75 minutes of vigorous-intensity aerobic activity per week, OR An equivalent combination of moderate and vigorous activity,* AND Muscle strengthening exercises on 2 or more days per week Balance exercise on 3 days per week if at risk for falling Types of physical activity for arthritis (5) Low-impact aerobic activities: brisk walking, cycling, swimming, water aerobics, gardening, group exercise classes, and dancing Muscle-strengthening exercises: calisthenics, Weight training, and working with resistance bands 2 Document any subjective or objective improvements: range of motion, muscle strength, weight reduction Monitor hematologic, hepatic, and renal function, as well as the GI, Blood Pressure (BP) and fluid status in all patients on long term NSAID therapy

3 the presence of inflammation Balance exercises: walking backwards, standing on one foot, and tai chi Evaluate for co-morbidities that can affect choice of pharmacotherapy: Age 60 years old, Congestive Heart Failure (CHF), Chronic Kidney Disease (CKD), Diabetes (DM), history of peptic ulcer disease (PUD), or increased gastrointestinal (GI) bleeding risk *A general rule is that 1 minutes of vigorous activity equals 2 minutes of moderate intensity activity (5) Pharmacologic Therapies Begin with scheduled doses of Acetaminophen (not to exceed 4 grams/day). If no results after 2-4 weeks and no contraindications, consider non-steroidal anti-inflammatory drugs (NSAIDs), or Cyclooxygenase-2 inhibitors (COX-2) with gastric protection if at risk for GI toxicity. (1). The Academy of Family Physicians does not recommend the routine use of Tramadol. Topicals: NSAIDs/salicylates/capsaicin Consider concomitant proton pump inhibitor (PPI) high dose therapy for gastric mucosal protection in appropriate at-risk patients on long-term NSAID: High Risk: o History of a previously complicated gastric ulcer, especially recent o 2 of the Moderate Risk Factors Moderate Risk (1-2 factors): o Age > 65 years o High dose NSAID therapy o A previous history of uncomplicated gastric ulcer o Concurrent use of aspirin (including low dose), corticosteroids, or anticoagulants Non-narcotic analgesics Opioids are being used more in patients with moderate to severe pain or diminished quality of life, but those using these drugs must be carefully selected and monitored because of the inherent adverse effects (10) Injections (see below) 3

4 Invasive Treatments - Knee Injections, Joint Replacement (1,2,6) For persistent symptoms, consider single dose of intra-articular corticosteroids For severe, disabling disease consider joint replacement Patients with complex co-morbidities or advanced disease, refer to Rheumatologist, Orthopedic surgeon (if considering knee replacement), or Physical Medicine specialist Coordinate followup care as needed Note: The American Academy of Orthopedic Surgeons is unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee due to inconclusive evidence. 1 Immunizations (8) Influenza Vaccination Document patient has received an influenza vaccination each year Document if adverse event occurs Administer vaccination yearly Yearly Pneumonia Vaccination Document patient has received a pneumonia vaccination Document if adverse event occurs 4 There are two different types of pneumococcal vaccines: PCV13 (pneumococcal conjugate vaccine) PPSV23 (pneumococcal polysaccharide vaccine) As indicated

5 Administer appropriate vaccine as indicated Tobacco Use (11-19) Provide smoking cessation counseling and other forms of treatment as a routine component of care Advise all individuals not to use tobacco products, or e- cigarettes (18) Advise no exposure to environmental tobacco smoke at work, home and public place (19) Tobacco use patterns Prior attempts to quit Readiness assessment Combination therapy with counseling and medications is more effective than either component alone Use of e-cigarettes e-cigarettes are not supported as an alternative to smoking or to facilitate smoking cessation (12,17) Factors to consider when choosing a pharmacotherapy (11) Clinician familiarity with the medications and contraindications for selected patients Previous patient experience with a specific pharmacotherapy (positive or negative) Think: 5 A's (13) Ask about smoking Advise to quit Assess willingness to quit Assist user to quit (i.e., refer to smoking cessation program and consider pharmacotherapy) Arrange follow-up Alcohol is associated with relapse so patients should consider limiting and/or abstaining from alcohol while quitting tobacco (11) Anticipate triggers or challenges that may occur when stopping tobacco. Discuss these with the patient so they can develop a plan to deal successfully with issues that arise (11) First line pharmacotherapy adjuvants (11,12,17) Nicotine replacement OTC - patch, gum, lozenge Rx nasal spray, inhaler Sustained-release bupropion Varenicline e-cigarettes (12,17) Not FDA approved or regulated Follow-up should begin within the first week after quit date. Second follow-up with the first month (11) In person Via telephone Assess at each visit: smoking status, weight gain, nicotine withdrawal symptoms 5

6 Patient characteristics (e.g., history of depression, concerns about weight gain Not enough information about safety or effectiveness for cessation One of the FDA-approved safe and effective cessation medications is recommended Depression Screening (20,21,22) Screen for presence of depression in adults aged 18 years, including pregnant and postpartum women (21) Have an adequate system in place to assure an accurate diagnosis, effective treatment, and appropriate followup (21) Use validated depression screening tool such as the Patient Health Questionnaire (PHQ-2 or PHQ-9), Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant women (20,22) Risk factors among the general adult populations vary by sex, age, race/ethnicity, education, marital status, geographical location, and employment status. Women, young and middle-aged adults, and nonwhite persons have higher rates depression than their counterparts, as do persons who are undereducated, previously married or unemployed (21) 6 USPSTF recommends screening all adults who have not been screened previously (21) Use clinical judgement and consideration of risk factors, comorbid conditions, and life events to determine if additional screening is warranted (21) Administer treatment and/or refer patients who meet criteria for depression to a mental health specialist Screening is suggested at subsequent visits Evaluate response to depression treatment with individualized follow-up contacts and adjust medication as indicated and/or confer with mental health specialist

7 Other groups at increased risk of developing depression are persons with chronic illnesses (e.g. cancer or cardiovascular disease), other mental health disorders (including substance misuse, or a family history of psychiatric disorders (21) Risk factors in older adults include disability, poor health status related to medical illness, complicated grief, sleep disturbances, loneliness, and history of depression age (21) Effective treatment of depression in adults generally includes antidepressants or specific psychotherapy approaches (e.g, CBT or brief psychosocial counseling), alone or in combination (21) * The FDA requested that sponsors of all non-steroidal anti-inflammatory drugs (NSAID) make labeling changes to their products. FDA recommended proposed labeling for both the prescription and over-the-counter (OTC) NSAIDs and a medication guide for the entire class of prescription products. All sponsors of marketed prescription NSAIDs, including Celebrex (celecoxib), a COX-2 selective NSAID, have been asked to revise the labeling (package insert) for their products to include a boxed warning, highlighting the potential for increased risk of cardiovascular (CV) events and the well described, serious, potential life-threatening gastrointestinal (GI) bleeding associated with their use. For more information see the FDA web site. 7

8 This guideline is intended as an educational reference and not as a substitute for the clinical judgment of the treating physician concerning appropriate and necessary care for a specific patient. This guideline is based on the clinical references listed at the end of the document. Note that a specific treatment or therapy listed may not be a covered benefit for all individuals. Please check the individual s eligibility and benefits plan. REFERENCE LIST 1. American Academy of Orthopedic Surgeons. (2013). Treatment of Osteoarthritis of the Knee; Evidence-Based Guideline Retrieved from eguideline.pdf 3. Patil P, Dasgupta B. (2012). Role of Diagnostic Ultrasound in the Assessment of Musculoskeletal Diseases. Therapeutic Advances in Musculoskeletal Diseases 4(5) Retrieved from pdf 5. Centers for Disease Control and Prevention (CDC). (2016). Physical Activity and Arthritis Overview. Retrieved from 7. Lanza FL, Chan FK, Quigley EM, et al. (2009). Guidelines for Prevention of NSAID Related Ulcer Complications. Am J Gastroenterol 104: Retrieved from 9. Hochberg MC, Altman RD, April KT, et al. (2012). American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research. Vol. 64, No. 4,, pp Retrieved from the%20use%20of%20nonpharmacologic%20and%20pharmacologic%20therapies %20in%20OA%20of%20the%20Hand,%20Hip%20and%20Knee.pdf 2. Lee J, Thorson D, Jurisson M, et al. (2007). Diagnosis and treatment of adult degenerative joint disease (DJD)/Osteoarthritis (OA) of the knee. Retrieved from 4. Centers for Disease Control and Prevention (CDC) and the Arthritis Foundation (2010) A National Public Health Agenda for Osteoarthritis Retrieved from 6. Fernandes L, Hagen KB, Bijlsma WJ, et al. (2013) EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.72: Retrieved from full.pdf 8. Centers for Disease Control and Prevention (CDC). (2016) Recommended Adult Immunization Schedule. Retrieved from Ringdahl E & Pandit S. (2011). Treatment of Knee Osteoarthritis. American Academy of Family Physicians. Vol 83 (11). Retrieved from 8

9 11. Agency for Healthcare Research and Quality (AHRQ) (2012). Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation. Retrieved from Naftilan, Allen J., Associate Professor of Medicine, Vanderbilt University Medical School; Clinical Director, The Heart Failure Program, The Vanderbilt Heart Institute, Nashville, Tennessee 13. Fiore MC, Jaen CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Retrieved from Hughes J, Stead L, Hartmann-Boyce J, Lancaster T. (2014). Antidepressants for smoking cessation (Review). Cochrane Database Syst Rev. Retrieved from Ann Wendling, MD, MPH. Medical Director, Tobacco Cessation. Healthways. Nashville, TN 14. Henningfield JE, Fant RV, Buchhalter AR, Stitzer ML. (2005). Pharmacotherapy for Nicotine Dependence. CA Cancer J Clin. 55: Retrieved from U.S. Preventive Services Task Force (USPSTF). (2015). Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. Retrieved from bacco-use-in-adults-and-pregnant-women-counseling-and-interventions1 18. American Diabetes Association. (2016). Standards of Medical Care in Diabetes The Journal of Clinical and Applied Research and Education. Diabetes Care. Vol. 38. Supplement 1 Retrieved from Smith SC Jr., Benjamin EJ, Bonow RO, Braun LT, Creager MA et al. (2011). American Heart Association/American College of Cardiology Foundation (AHA/ACCF). AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2011 Update. A Guideline from the American Heart Association and American College of Cardiology Foundation: Endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. Circulation. 2011; 124: Retrieved from Kroenke K, Spitzer RL, Williams JB. (2001). The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001; 16: Retrieved from 9

10 21. U.S. Preventive Services Task Force (USPSTF). (2016). Depression in Adults: Screening Retrieved from depression-in-adults-screening1 22. Institute for Clinical Systems Improvement (ICSI) (2016). Depression, Adult in Primary Care. Retrieved from more/catalog_guidelines_and_more/catalog_guideline s/catalog_behavioral_health_guidelines/depression 10