9.Osteoarthritis

8/9/2019 9.Osteoarthritis

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OSTEOARTHRITISOSTEOARTHRITISin older peoplein older people

Edu TehupeioryEdu Tehupeiory

Sub-division of RheumatologyInternal Medicine epartment! Medical "acultyHasanudin #niversity

Ma$assar



EpidemiologyEpidemiology

Osteoarthritis (OA) is a common, chronic,Osteoarthritis (OA) is a common, chronic,musculoskeletal disorder.musculoskeletal disorder.Symptomatic OA, particularly of the kneeSymptomatic OA, particularly of the knee

and hip, is the most common cause ofand hip, is the most common cause ofmusculoskeletal disability in the elderlymusculoskeletal disability in the elderly(felson et al 1987).(felson et al 1987).adiolo!ists and patholo!ists coint the termadiolo!ists and patholo!ists coint the term

"osteoarthritis# ori!inally, to describe the"osteoarthritis# ori!inally, to describe theappearances of o$er!ro%th of the mar!inalappearances of o$er!ro%th of the mar!inaland subchondral bone.and subchondral bone.

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'atholo!ically, the dominant process is that'atholo!ically, the dominant process is thatof focal destruction of articularl cartila!e,of focal destruction of articularl cartila!e,accompanied by hypertrophic reaction at theaccompanied by hypertrophic reaction at the

oint mar!ins and in the subchondral bone. oint mar!ins and in the subchondral bone. he current $ie% of OA is that represents a he current $ie% of OA is that represents ahetero!eneous !roup of o$erlappin!hetero!eneous !roup of o$erlappin!patholo!ical conditions, causin! dama!e topatholo!ical conditions, causin! dama!e to

the articular cartila!e and leadin! to clinicallythe articular cartila!e and leadin! to clinicallyand radio!raphically reco!ni*ed impairmentand radio!raphically reco!ni*ed impairmentof the oints disability of the patient.of the oints disability of the patient.

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%linical "eatures%linical "eatures

OA esult in painful sti oints %ith limitedOA esult in painful sti oints %ith limitedmo$ement.mo$ement.

he pain of osteoarthritis tends to %orsen he pain of osteoarthritis tends to %orsen

on use and may often occur at ni!ht after aon use and may often occur at ni!ht after aperiod of rest.period of rest. -oint sti ness also increases %ith inacti$ity -oint sti ness also increases %ith inacti$ityand may occur at ni!ht but should not lastand may occur at ni!ht but should not lastlon!er than + minutes (in contrast %ithlon!er than + minutes (in contrast %iththe sti ness associated %ith in/ammatorythe sti ness associated %ith in/ammatoryarthritis).arthritis).

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Some indi$iduals de$elop aSome indi$iduals de$elop acharacteristic pattern of ointcharacteristic pattern of ointin$ol$ement, a ectin! the handsin$ol$ement, a ectin! the hands(distal interphalan!eal oints,(distal interphalan!eal oints,pro imal interphalan!eal oints, andpro imal interphalan!eal oints, and11 stst carpometacarpal oints), hips,carpometacarpal oints), hips,knees, and spine symmetrically2 thisknees, and spine symmetrically2 thispattern is often familial.pattern is often familial.

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%linical Assesment%linical Assesment

he main reasons for %hich an OA patient he main reasons for %hich an OA patientseeks medical help are pain and functionalseeks medical help are pain and functionalimpairment.impairment.

4o%e$er, the correlation bet%een pain4o%e$er, the correlation bet%een painse$erity, and structural chan!es is poorse$erity, and structural chan!es is poorand the conse5uences of pain andand the conse5uences of pain andimpairment on indi$iduals $ary dependentimpairment on indi$iduals $ary dependent

upon their personality, a ect, occupationupon their personality, a ect, occupationpsychosocial en$ironment, andpsychosocial en$ironment, ande pectations (6rand et al 1998).e pectations (6rand et al 1998).



n$esti!ations should includen$esti!ations should includein/ammatory markers (erythrocytein/ammatory markers (erythrocytesedimentation rate ( S ):;<reacti$esedimentation rate ( S ):;<reacti$eprotein (; '), %hich should beprotein (; '), %hich should benormal, and radio!raphs of a ectednormal, and radio!raphs of a ected

oints. oints.

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%linical Management%linical Management

S ='> and SA? inter$entions should beS ='> and SA? inter$entions should beutili*ed @rst (?i!ure 1 and ?i!ure &).utili*ed @rst (?i!ure 1 and ?i!ure &).ducation, social support, physiotherapyducation, social support, physiotherapy(both speci@c muscle stren!thenin! and(both speci@c muscle stren!thenin! and!eneral @tness), occupational therapy,!eneral @tness), occupational therapy,acupuncture and transcutaneous electricalacupuncture and transcutaneous electricalner$e stimulation ( BS) are non<ner$e stimulation ( BS) are non<pharmacolo!ical therapies %ithpharmacolo!ical therapies %ithestablished e$idence<based eCcacyestablished e$idence<based eCcacy('endleton et al & )('endleton et al & )

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OA of the & st %M%'

'ra!matic mana!ement al!orithm

1. ;heck correct dia!nosis ( S normal, D<ray chan!es)&. opical BSA Es+. opical capsaicin0. Simple anal!esics3. Oral BSA Es:;OD<& inhibitors. >ocal corticosteroid in ection7. Sur!ery

"igure ( & ) Management of osteoarthritis of the*rst carpo-metacarpophalangeal +oint



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OA of the $nee

'ra!matic mana!ement al!orithm

1. ;heck correct dia!nosis( S normal, D<ray chan!es)

&. opical BSA Es +. Simple anal!esics 0. Oral BSA Es:;OD<& inhibitors 3. >ocal corticosteroid in ection . 4yaluronan:tidal irri!ation 7. Arthroscopic %ashout:sur!ery

"igure ( , ) Management of osteoarthritis of the$nee .al$er-/one et al ,0001



'harmacolo!ical therapies are utili*ed as'harmacolo!ical therapies are utili*ed assecond<life for uncontrolled pain.second<life for uncontrolled pain.

he results of meta<analyses ha$e sho%n he results of meta<analyses ha$e sho%n

e$idence for the safety and e ecti$eness ofe$idence for the safety and e ecti$eness oftopical non<steroidal anti in/ammatory dru!stopical non<steroidal anti in/ammatory dru!sin osteoarthritis ('endleton et al & ).in osteoarthritis ('endleton et al & ).

opical capsaicin, the natural substance found opical capsaicin, the natural substance found

inside the %hite "ribs# of hot chili peppers andinside the %hite "ribs# of hot chili peppers andresponsible for the familiar "burnin!#responsible for the familiar "burnin!#sensation, re$ersibly depletes substance '.sensation, re$ersibly depletes substance '.

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A meta<analysis concluded that capsicinA meta<analysis concluded that capsicin%as useful in the treatment of OA %ith%as useful in the treatment of OA %ithodds ratio in /a$our of capsaicin o$erodds ratio in /a$our of capsaicin o$er

placebo of 0.+ (Fhan! G >i<Han<'o,placebo of 0.+ (Fhan! G >i<Han<'o,1990).1990).4o%e$er, placebo<controlled trials %ith4o%e$er, placebo<controlled trials %iththis a!ent, %hich causes pronouncedthis a!ent, %hich causes pronouncedburnin!, are understandably diCcult andburnin!, are understandably diCcult andmost studies sho% profoundly positi$emost studies sho% profoundly positi$ee ects of topical placebo.e ects of topical placebo.

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'aracetamol in doses up to 0!:day is safe'aracetamol in doses up to 0!:day is safeand e ecti$e in OA ('endleton et al, & ).and e ecti$e in OA ('endleton et al, & ).Hhen paracetamol is compared to non<Hhen paracetamol is compared to non<

steroidal anti<in/ammatory dru!ssteroidal anti<in/ammatory dru!s(BSA Es), none of the assessed outcomes(BSA Es), none of the assessed outcomes(pain at rest, pain on motion, %alkin! time(pain at rest, pain on motion, %alkin! timeo$er 3 feet, and 5uality of life measures)o$er 3 feet, and 5uality of life measures)sho%ed a si!ni@cant ad$anta!e of thesho%ed a si!ni@cant ad$anta!e of theBSA Es o$er simple anal!esics.BSA Es o$er simple anal!esics.

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Eespite an absence of lon!<term data,Eespite an absence of lon!<term data,and short<term studies that sho%and short<term studies that sho%ad$anta!e for BSA Es o$er placebo butad$anta!e for BSA Es o$er placebo butha$e hi!h drop out rates.ha$e hi!h drop out rates.BSA Es ha$e remained a popularBSA Es ha$e remained a popularchoice for the mana!ement of OA.choice for the mana!ement of OA.

BSA Es are still persistently prescribedBSA Es are still persistently prescribedas @rst<line therapy and many patientsas @rst<line therapy and many patientspurchase ibuprofen o$er the counter.purchase ibuprofen o$er the counter.

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A!ainst this backdrop, the ;OD<& inhibitorsA!ainst this backdrop, the ;OD<& inhibitors%ere marketed in the late 199 s%ere marketed in the late 199 sShort<term studies demonstratin!Short<term studies demonstratin!comparable pain<relie$in! properties incomparable pain<relie$in! properties inarthritis patients (6ombardier et al & ),arthritis patients (6ombardier et al & ),but %ith a 3 K reduction in endoscopicbut %ith a 3 K reduction in endoscopiculceration (6ombardier et al & ), led toulceration (6ombardier et al & ), led toa rapid proliferation in prescriptions fo OAa rapid proliferation in prescriptions fo OA(Shau!hnessy G Lordon, & )(Shau!hnessy G Lordon, & )

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4o%e$er, the cardio$ascular safety of rofeco ib4o%e$er, the cardio$ascular safety of rofeco ib%as 5uestioned soon after licensin! and dru! %as%as 5uestioned soon after licensin! and dru! %as%ithdra%n by its manufacturers in & 3, amidst%ithdra%n by its manufacturers in & 3, amidststudy results su!!estin! a si!ni@cantly increasedstudy results su!!estin! a si!ni@cantly increasedrisk of cardio$ascular disease (Shau!hnessy Grisk of cardio$ascular disease (Shau!hnessy GLordon, & ).Lordon, & ).ecently, studies ha$e 5uestioned cardio$ascularecently, studies ha$e 5uestioned cardio$ascularsafety of con$entinal BSA Es and MtraditionalN OAsafety of con$entinal BSA Es and MtraditionalN OAdru!s such as diclofenac and ibuprofen h$a beendru!s such as diclofenac and ibuprofen h$a beenimplicated in increased susceptibility toimplicated in increased susceptibility tocardio$ascular disease (Jearney et al & ).cardio$ascular disease (Jearney et al & ).

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'ra!matically , there is little e$idence to'ra!matically , there is little e$idence tosupport the lon!<term eCcacy of eithersupport the lon!<term eCcacy of eitherBSA Es or ;OD<& inhibitors for the pain ofBSA Es or ;OD<& inhibitors for the pain of

OA and , %hilst there is considerableOA and , %hilst there is considerableuncertainty about the cardio$ascularuncertainty about the cardio$ascularsafety of these pharmacolo!icalsafety of these pharmacolo!icalinter$entions, they are best reser$ed asinter$entions, they are best reser$ed asthird<line therapies, prescribed only afterthird<line therapies, prescribed only afterassesment of cardio$ascular risk factors.assesment of cardio$ascular risk factors.

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he "4oly Lrail# for OA remains the callen!e of he "4oly Lrail# for OA remains the callen!e of@ndin! a!ent %ith chondroprotecti$e properties.@ndin! a!ent %ith chondroprotecti$e properties.

o date, there has been no con$icin! e$idence o date, there has been no con$icin! e$idence

from human studies that chondoprotectionfrom human studies that chondoprotectioncould e$en be achie$ed, but there ha$e beencould e$en be achie$ed, but there ha$e beendata from animalm studies, and the emer!encedata from animalm studies, and the emer!enceof !lucosamine sulphate, chondroitin sulphate,of !lucosamine sulphate, chondroitin sulphate,a$ocado, and soya unsaponi@ables, diaceirin,a$ocado, and soya unsaponi@ables, diaceirin,and hyaluronic acid ha$e su!!ested that,and hyaluronic acid ha$e su!!ested that,theoretically, cartila!e dama!e could betheoretically, cartila!e dama!e could bepre$entable.pre$entable.

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n particular, initial studies %ithn particular, initial studies %ith!lucosamine sulphate and!lucosamine sulphate andchondroitin sulphate sho%ed promisechondroitin sulphate sho%ed promisebut more recent studies ha$e failedbut more recent studies ha$e failedto sho%ed promise but more recentto sho%ed promise but more recentstudies ha$r failed to sho%ed promisestudies ha$r failed to sho%ed promise

but more recent studies ha$e failedbut more recent studies ha$e failedto sho% si!ni@cant e ect (;le!! et al.to sho% si!ni@cant e ect (;le!! et al.& 2 =cAlindon, & )& 2 =cAlindon, & )

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ntra<articular corticosteroids are fre5uently usedntra<articular corticosteroids are fre5uently usedin OA , particularly in a oint %ith si!ni@cantin OA , particularly in a oint %ith si!ni@cante usion or other si!ns of in/ammation.e usion or other si!ns of in/ammation.

here are se$eral small randomi*ed controlled here are se$eral small randomi*ed controlledtrials that con@rm the short<term eCcacy of thistrials that con@rm the short<term eCcacy of thisapproach (Halker<6one et al & ).approach (Halker<6one et al & ).4o%e$er, this approach usually represents a4o%e$er, this approach usually represents apalliation in OA. Should symptoms recur, referalpalliation in OA. Should symptoms recur, referalfor arthroscopy and:or sur!ery %ould usually befor arthroscopy and:or sur!ery %ould usually beconsidered unless the patient is medically un@tconsidered unless the patient is medically un@tfor sur!ical inter$entionfor sur!ical inter$ention

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9.Osteoarthritis