#63 – Osteoarthritis Treatment



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Quick Osteoathritis Review

  • Signs and Symptoms
    • Progressive joint pain
      • Stage 1 – Intermittent, Predictable, limits only high-impact activities
      • Stage 2 – Constant, effects daily activities
      • Stage 3 – Constant with intermittent, unpredictable, intense pain with severe limitations
    • Worse in the afternoon
    • Decreased ROM
    • Joint-line tenderness
    • Swelling and effusions
  • Radiography
    • 4 Radiographic Criteria of Osteoarthritis
      • Diminished joint space
      • Bony sclerosis
      • Osteophytes
      • Subchondral cyst


General Osteoarthritis Treatment Principles

  • Education
    • Discuss modifiable risk factors
    • Prognosis
    • Treatment options and timeline
  • Goal Setting
    • Identify current issues
    • Set priorities
    • Develop realistic plan
      • Multiple short term goals to achieve long term goal
      • Directed at minimizing pain, optimizing function, and modify joint damage
  • Clinical Assessment and Follow-up
    • Should be every 3 months by provide
    • Factors to be addressed and discussed during visits:
      • Impact of pain on daily living and quality of life
      • Functional limitations
      • Recreational and/or occupational aspirations
      • Sleep disturbances
      • Fall risk assessment
      • Expectations of treatment

Updated Guidelines from ACR/AAF

2019 updated guidelines from American College of Rheumatology and American Arthritis Foundation


Non-Pharmacologic Treatment

  • Should be first line either alone or with pharmacologic therapy
  • Physical therapy is the mainstay of non-pharmacologic treatment
    • Usually 6 weeks
  • Weight loss
    • Loss of 10% of body weight equals 50% reduction in pain scores
    • Adipokines (leptin and adiponectin) released by adipose tissue are known inflammatory factors
    • Consultation with dietician can be helpful
  • Exercise
    • Exercising have comparable effects on pain and function compared to NSAIDs
    • Low-impact is best, but tailor to patient’s function and limitations
    • Activities to help with core strength and balance can have significant reductions in falls
  • Braces and Splints
    • When possible, these aids can have significant benefit in pain reduction during activities

Pharmacologic Treatments

  • Topical NSAIDs should be considered prior to oral NSAIDs
    • Knee > hand efficacy
    • Diclofenac 1% gel – 4g (large joints) or 2g (small joints) applied 3-4x/day
      • Now available OTC
  • Oral NSAIDs > acetaminophen
    • COX-2 selective NSAID
      • Celecoxib 100-200mg daily or BID
      • Diclofenac 75mg BID
      • Meloxicam 10-15mg daily
  • Duloxetine can be helpful
    • Desensitizes central nociceptive pain processing
    • 60-120mg daily
  • Intrarticular glucocorticoid injections have limited role
    • Can be used for short-term relief
      • Most helpful with the hip
      • Long-term use can damage cartilage
    • Triamcinolone 40mg
  • Hyaluronic acid is controversial with limited data
  • Avoid recommended glucosamine, chondroitin, vitamin D, and fish oil due to lack of clear data showing benefit

Surgical Indications and Management



Cottage Physician (1893)



References

  1. Hawker GA, Stewart L, French MR, et al. Understanding the pain experience in hip and knee osteoarthritis–an OARSI/OMERACT initiative. Osteoarthritis Cartilage. 2008; 16(4):415-22. [pubmed]
  2. French SD, Bennell KL, Nichols PJ, Hodges PW, Dobson FL, Hinman RS.  What do people with knee or hip osteoarthritis need to know? An international consensus of essential statements for osteoarthritis.  Arthritis Care Res (Hoboken). 2015;57(6):809. [pubmed]
  3. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002; 288(19):2469-75. [pubmed]
  4. Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013; 310(12):1263-73. [PDF]
  5. Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010; 18(4):476-99. [pubmed]
  6. 2019 American College of Rheumatology/Arthritis Foundation Guideline for Management of Osteoarthritis of the Hand, Hip, and Knee.  Arthritis Care Res (Hoboken). 2020;72(2):149-162. [pubmed]

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