UPDATES ON MANAGEMENT OF OSTEOARTHRITIS August 10, 2014 Dr. Suneil Kapur Assistant Professor of Medicine, University of Ottawa Associate Staff Rheumatologist, The Ottawa Hospital
Learning Objectives Upon successfully completing this continuing education lesson, you will be better able to: Describe some of the differences between inflammatory and non-inflammatory arthritis and acute and chronic pain Identify patients having early symptoms of or at risk for osteoarthritis (OA) Describe the roles of multi-disciplinary team members in managing OA Discuss non-drug and drug treatment approaches to managing hand, knee or hip OA
Understanding Pain Inflammatory Pain vs. Non-Inflammatory Pain
Understanding pain Acute Chronic
What is Osteoarthritis Slowly progressive musculoskeletal disorder Cartilage is wearing away Boney enlargement Bone on bone Inflammatory osteoarthritis Generalized osteoarthritis
Osteoarthritis (OA) What areas are affected by OA?
X-Ray of Hip with OA and Normal Hip
X-Ray of Normal Knee and OA of Knee
X-Ray of Osteoarthritis of the Hand
Impact of OA OA affects 1 in 8 Canadians 4.4 million people affected (2010) Of these, 500,000 suffer with moderate to severe disability Expect it to rise to 10.4 million in 2040
Risk Factors for Osteoarthritis Age Female versus male sex Obesity Lack of Osteoporosis Occupation Sports activities Previous injury Muscle weakness Proprioceptive deficits Genetic elements Acromegaly Calcium crystal deposition disease
Pathogenesis Exercise and mechanical loading Genetic Predisposition Proteases Collagenase Stromelysin Gelatinase TIMPs Cytokines Catabolic Anabolic Nitric Oxide Calcium crystals Aging
Does too much physical activity cause OA? Australian study.. about 39,000 participants Endpoint - Total Hip Replacements(THR) & Total Knee Replacement (TKR) Vigorous activity - sweating & out of breath.. 1-2X/week - TKR (HR 1.42) at least 3X/week - TKR (HR 1.24) Less vigorous activity (walking) no risk for TKR Activity not related to THR Wang Y et al. J Rheum; 2011;38:350-7.
Diagnose Knee Osteoarthritis in 4 minutes ASK 4 questions: Consistent/intermittent discomfort or pain 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) http://www.arthritisresearch.ca/video-gallery-all/viewcategory/17/instructional-videos.html Cibere et al. Association of Clinical Findings With Pre Radiographic and Radiographic Knee Osteoarthritis in a Population-Based Study. Arthritis Rheum 2010;62(12):1691-8.
Introducing Amita 62-year-old female (5 1 tall and weighs 187 pounds BMI of 27) Her pain is consistent with knee OA for the past 6 months Physiotherapy, exercise and ice therapy have provided some relief PMH includes type 2 DM, hyperlipidemia and hypertension No gastrointestinal, cardiovascular or renal disease Acetaminophen 500 mg 4 times daily for 3 months has not improved symptoms She is considering nutritional supplements such as glucosamine or chondroitin
Multidisciplinary care In addition to primary care physicians and rheumatologists, the ideal treatment approach should incorporate patient values and the use of a multi-disciplinary team including 4,8,9 : Physiotherapists Occupational therapists Dietitians Psychologists or social workers Pharmacists
Goals of Therapy Reduce joint pain Improve joint function and mobility Maintain normal articular and periarticular structures Prevent joint cartilage damage
ACR recommendations (Knee) Non-pharmacological
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):2026 2032.
ACR recommendations (Knee) Initial Therapy Management - Pharmacological Recommendations
Acetaminophen safety The maximum dose of 4 grams per day should have some cautions: Potential for elevated hepatic enzymes Risk for hepatotoxic risk higher in regular users of alcohol Little evidence for dose ceiling of 4 grams Safety profile may be better than NSAID USE Less risk for platelet dysfunction, GI ulceration, renal dysfunction
Safe use of NSAIDs ACR makes recommendations regarding the safe use of NSAIDs in specific patient populations Patients 75 years of age or older Patients with a history of a symptomatic or complicated upper GI ulcer but without a GI bleed in the past year Patients who have experienced a GI bleed within the past year Patients with chronic kidney disease Patients taking low-dose ASA for cardioprotection
ACR 2012 OA Guidelines: Knee OA 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):465 474.
One Possible Pain Mechanism Centrally mediated pain
Evidence for duloxetine use in knee OA Patients were randomized to duloxetine 60 mg or placebo; at week 7, patients on duloxetine were randomized to stay on current dose or increase to 120 mg dose Primary outcome was a reduction in the 24-hour average pain score using an 11-point Likert scale More patients on duloxetine achieved at least a 50% reduction in pain score at week 13 (47.2% vs. 29.4%, p<0.006
ACR recommendations (Hip) Non-pharmacologic
ACR recommendations (Hip) Initial Therapy Management - Pharmacological Recommendations
Introducing Amita 62-year-old female (178 cm tall and weighs 85 kg BMI of 26.8kg/m 2 ) Her pain is consistent with knee OA for the past 6 months Physiotherapy, exercise and ice therapy have provided some relief PMH includes type 2 DM, hyperlipidemia and hypertension No gastrointestinal, cardiovascular or renal disease Acetaminophen 500 mg 4 times daily for 3 months has not improved symptoms She is considering nutritional supplements such as glucosamine or chondroitin
2 months later You recommended that Amita increase her dose of acetaminophen to 3.2 grams daily for two months. Two months later she returns and reports that her pain continues to bother her daily and is interfering with her daily activities. She has now seen a dietitian, as she is very motivated to lose weight. What are the next steps for Amita?
Next Steps for Amita The ACR recommends that, for patients who do not achieve a satisfactory clinical response to intermittent use of OTC acetaminophen, or OTC NSAIDs, that the next treatment options include full-dose, daily acetaminophen, a topical or oral NSAID (unless it is contraindicated in the patient), tramadol or intraarticular corticosteroid injection. If there is an inadequate response to an initial trial of fulldose acetaminophen, treatment options include an oral or topical NSAID, intraarticular corticosteroid injection, tramadol, duloxetine or intraarticular hyaluronic acid.
Thank you! Questions?
References
ACR recommendations (Hand) Non-Pharmacological Recommendations
ACR recommendations (Hand) Initial Therapy Management - Pharmacological Recommendations