First MTP Osteoarthritis Hallux valgus with bunion

OA is a Problem with the Cartilage!

Osteoarthritis: Risk Factors Secondary Osteoarthritis: The degeneration is secondary to an injury to the cartilage Primary Osteoarthritis: No obvious cartilage injury Erosive (hand) OA: runs in families, autosomal dominant but more penetration in women Often starts 5-10 years pre to post menopause, adds more joints (DIPs, PIPs), can mimic psoriatic arthritis, burns out with bony changes

Risks for OA Advanced Age Female Genetics Obesity Occupation (overuse) Trauma

Osteoarthritis: Laboratory All laboratory investigations should be normal in osteoarthritis Labs and Xrays are not necessary to make the diagnosis

Osteoarthritis: Management Non-Pharmacologic Exercises Strengthening Splinting Pharmacologic Oral Medications Surgery Topical Medications Injectable Medications Alternative/Complimentary Choices

Goals of Treatment Pain Reduction Improved Function Changes the Disease Outcome Low Cost Low Side Effects

Physical & Occupational Therapy Proper Footwear Strength Training Assistive Devices Physical & Occupational Therapy Exercise & Weight Loss Education

Topical Medications Capsaicin Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Pennsaid, Diclofenac

Topical NSAIDs Messy Benefits Little systemic absorption Limited Use for Osteoarthritis Small effects in clinical trials Apply 4 times per day Expensive Messy Benefits Little systemic absorption

Intra-Articular Corticosteroids Pros Cheap Relatively Safe: 1 in 15-20,000 risk of infection Safe to do 4 injections in a single joint per year Cons Short term benefit at 4 to 8 weeks but negative at 12 and 24 weeks Predictors of response are unclear

Viscosupplementation Joints typically contain a small amount of lubricating fluid called synovial fluid. Hyaluronic acid is a component of this synovial fluid Synovial fluid Hyaluronic acid is decreased in patients with osteoarthritis Viscosupplements are synthetically or biologically derived Hyaluronic Acid

Viscosupplementation Given by a series of 1 to 3 injections once a week depending on the product Only approved for osteoarthritis of the knee The effects are variable lasting months in some people and not working at all in others

Viscosupplementation Pros If it works, may have a significant benefit Cons Expensive ~ $300 per course The effects are variable lasting months in some people and not working at all in others Post-injection pain, swelling Not very good clinical trial data

Oral Medications Simple Analgesics Non-Steroidal Anti-Inflammatory Medications (NSAIDs) Narcotic Analgesics and non-narcotic (tramadol) Complimentary Therapy (Glucosamine)

Acetaminophen Acetaminophen (Tylenol ) Useful in mild to moderate osteoarthritis Pros Cheap Safe Proven Benefit Cons Small effect Often need 3g/day

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Traditional NSAIDs COX-2 Selective NSAIDs (COXIBs)

Prostaglandin Synthesis Cell Membrane Phospholipids Arachidonic Acid NSAIDs NSAIDs COX-1 COX-2 Prostaglandins Prostaglandins COX-1 Continuously Expressed GI Tract Platelets Endothelium Kidney COX-2 Upregulated Synovial Lining Macrophages Chondrocytes Endothelium Macula Densa

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Traditional NSAIDs Block the Actions of COX-1 and COX-2 Available Over the Counter (Ibuprofen) Several (Ibuprofen, Diclofenac, Naproxen, etc) COX-2 Selective NSAIDs (COXIBs) Only Block the Action of COX-2 Only 1 available – Celecoxib (Celebrex)

NSAIDs & COXIBs: What Works NSAIDs consistently outperform acetaminophen in OA treatment

NSAIDs & COXIBs: What to look out for GI Risk – gastric and duodenal ulcer Renal Risk – raise creatinine and HTN Cardiovascular Risk - ?increased MIs Hepatoxicity Edema Allergic reactions

Clinical Risk Factors for NSAID Gastropathy History of Ulcer Related Complications 13.5% Previous ulcer, bleeding Multiple NSAIDs 9.0 % High-dose NSAIDs 7.0 % Concomitant Anticoagulation 6.4% Age > 69 5.6% Age > 59 3.1% Concomitant Steroids 2.2% History of CV disease 1.8%

More Patients are Without Appropriate Gastroprotection Patients >65 years not receiving gastroprotective approaches with their NSAIDs (%) Year 100 80 60 40 20 Singh G, et al. Gastroenterology 2006; 130(Suppl. 2): A-82 (Abstract 564).

NSAIDs & COXIBS: Cardiovascular All NSAIDs may increase the risk of MI (possibly) and some more than others Use the lowest possible dose for the shortest duration of time

Narcotics Benefits Side Effects Risk for Falls and other Accidents Codeine does have some evidence for efficacy, however, it also has a high incidence of side-effects. Oxycodone, morphine, and hydromorphone may be better choices Side Effects Increaed in the elderly Sedation, confusion, constipation Risk for Falls and other Accidents

Addiction It is EXCEEDINGLY rare for patients with OA to show addictive behaviour. In fact, a study of over 800 patients with OA treated with opioids for 3 years found only 4 (0.02%) to have addictions. (Ytterberg S, Mahowald M, Woods S. Codeine and oxycodone use in patients with chronic rheumatic disease pain. Arthritis Rheum 1998;41:1603-12.) OA patients stop opioids after surgery. (Visuri T, Koskenvuo M, Honkanen R. The influence of total hip replacement on hip pain and the use of analgesics. Pain 1985;23:19-26.)

Glucosamine: The Theory Glucosamine is a component of cartilage Glucosamine is reduced in osteoarthritic cartilage Replacing glucosamine may have beneficial effects

Glucosamine: The Evidence You are a believer or not Both positive and negative trials Withdrawal trial and NIH trial were both essentially negative DONA (RottaPharm) Only brand of glucosamine to show positive benefit in trials All trials sponsored by pharmaceutical company

Glucosamine: Practicality Dose: 500 mg three times daily If no effect after 3 months stop ? Take with chondroitin Seems very safe

Surgery for Osteoarthritis

Surgery: Who is appropriate Most people with arthritis, including older individuals, should be referred for surgical treatment when other treatment is ineffective and function is impaired. Surgery should not be used as a last resort There is no “magic age” for surgery

Surgery: Why Consider Consider surgery before: Advanced muscle weakness Joint deformities Significant loss of function with further deconditioning

Treatment Conclusions Non-Pharmacologic Therapy Education Physical Therapy Assessment Strengthening Range of Motion Joint Protection & Energy Conservation Weight Loss & Nutrition Cardiovascular Exercise Shoes & Insoles Assistive Devices

Treatment Conclusions NSAIDs Work very well in select patients Try a few NSAIDs before find the right one for you. 3 week trials of at least 3 different NSAIDs. Injectable Corticosteroids Work well in some patients Viscosupplementation Can work well in some patients (milder disease) Opioids Can provide considerable benefit

Treatment Conclusions Lack of Scientific Evidence for Acupuncture Magnet Therapy

OA Guidelines Other Exercise Brace, Taping Weight Loss Joint replacement Medications Acetaminophen NSAIDs/Coxibs Topical agents Injectable agents

Questions