Transcript Management of Osteoarthritis

MANAGEMENT OF
OSTEOARTHRITIS
Carrie Johnson, Pharm.D., CDE
Assistant Professor
[email protected]
Objectives
Understand the basic pathophysiology of
osteoarthritis
 Identify underlying etiology
 Describe clinical manifestations of
osteoarthritis
 Understand diagnostic criteria for
osteoarthritis
 Recommend various non-pharmacologic
and pharmacologic treatment strategies

Meet K.W.
70 YOF presents to your clinic for regular follow-up. She
complains of increasing pain in her lower back, hips and
right knee. Six months ago, she was started on APAP 500
mg 4x daily. Pt complains of continued moderate to
severe pain despite treatment.
 Review of systems:
pain / stiffness in right knee
 shooting pain in lower back
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Physical Exam
well-developed
 obese
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Meet K.W.
PMH (including medications)
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Osteoarthritis
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Type 2 DM
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Atorvastatin 10mg PO QHS
HTN
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Metformin 500mg PO BID
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Hyperlipidemia
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APAP 500mg (2 PO QID
PRN)
Pertinent Labs
Lisinopril 10mg PO Qday
Obesity
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Gluc 248, A1C 8.1%
Na 135, K 4.7
BUN 15, SCr 1.6
Hgb 12.8, Hct 36.7%,
PLT 286k
AST 38, alk phos 96
TG 184, TC 206, LDL
137
Epidemiology
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46 million adults have self-reported doctordiagnosed arthritis.
19 million have arthritis and arthritisattributable activity limitation.
67 million adults ≥ 18 years will have doctordiagnosed arthritis by the year 2030.
25 million adults with arthritis will report
arthritis-attributable activity limitations.
Epidemiology
Kentucky (state data)
2003
2005
2007
1,044,000
879,000
958,000
Adults limited by arthritis
519,000
395,000
465,000
% of adults with arthritis
35
29
32
38/31
34/24
35/28
% whites with arthritis
35
29
32
% blacks with arthritis
28
25
33
% Hispanics with arthritis
26
17
18
% 18–44 year olds with arthritis
19
14
15
% 45–64 year olds with arthritis
46
40
43
% 65+ year olds with arthritis
61
51
58
% with arthritis who are overweight or obese
68
72
73
% with arthritis who are physically inactive
36
35
32
Adults with arthritis
% women/men with arthritis
Epidemiology
Etiology & Risk Factors
Age
 Men vs. women
 Obesity
 Quadricep muscle weakness
 Joint overuse / injury
 Genetics
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Question about K.W.
Which of these risk factors does K.W. have?
Pathophysiology
Synovium
Articular Cartilage
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Degradation > synthesis
Loss of articular cartilage
Subchondral bone
thickening
Osteophyte formation
Progressive joint space
narrowing
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Decreased concentrations
of hyaluronan
Overall thickened
synovium
Pathophysiology
Signs & Symptoms
Stiffness of joints
 Deep, aching pain
 Crepitus
 Joint enlargement

Joints Involved
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Distal interphalangeal joint (DIP)
 Herberden’s nodes
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Proximal interphalangeal joint (PIP)
 Bouchard’s nodes
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Knees
Hips
Cervical / lumbar spine
Joints Involved
Diagnosis
History
 Physical exam
 Characteristic radiographic findings
 Hip OA vs. knee OA
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 Different
guidelines for different locations
Treatment Options
Treatment Goals
Patient education about disease state
 Relieve pain and stiffness
 Maintain or improve joint mobility
 Limit functional impairment
 Improve quality of life
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Treatment Algorithm
Non-Pharmacologic Treatment
Educate patient about disease state
 Weight loss
 Physical therapy / Exercise
 Heat / cold therapies
 Assistance devices
 Surgical procedures
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Pharmacologic Treatment
Oral Agents
Acetaminophen
 NSAID
 Glucosamine +
chondroitin
 Narcotic analgesics
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Non-oral Agents
Corticosteroids
 Hyaluronate
injections
 Capsaicin
 Counterirritants
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Glucosamine + Chondroitin
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Dose: 1500mg/day glucosamine; 1200mg/day
chondroitin
Can be initiated at any time during treatment
algorithm
> 15 double-blind, placebo controlled trials
 Slows
loss of cartilage in knees
 Reduces joint space narrowing and pain
 At 8 years, rates of lower limb joint replacement
was 50% that of placebo
Glucosamine + Chondroitin
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Contraindications
 Shellfish allergy
 Asthma
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Adverse effects
 GI
 Possible
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hypersensitivity
Interactions
 Warfarin
 Diabetes
medications
S Dahmer, Schiller RM. Am Fam Physician. 2008;78(4):471–476, 481
Acetaminophen
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First line therapy
MOA: central COX inhibition
Dose: 325mg – 650mg 4x daily
Well-tolerated
DDI
Caution with patients with baseline liver
dysfunction
Pt education
Question about K.W.
What is K.W. doing wrong with her therapy?
NSAIDs
Second line therapy
 MOA: central & peripheral COX inhibition
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 Analgesic
effect within 1-2 hours
 Controversy
of COX-2 inhibitors
All have similar efficacy in pain
management
 Adverse effects
 Drug – drug interactions
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Capsaicin
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Extracted from red peppers
Depletes substance P from nerve fibers
Must use regularly
 4x
daily
 Can taper to BID application
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Adverse Effects: burning / stinging
Corticosteroids
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Dosing
Systemic therapy not recommended
Rapidly effective / short duration of efficacy
Intra-articular injections
 Pain
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relief with local inflammation / joint effusion
Uncertain long-term benefit
Limit of 3-4 injections / year
Minimize joint activity / stress directly after
injection
Hyaluronate Injections
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Lubricant in normal cartilage
Efficacy
 Amount
decreases in OA
 Reduces symptoms of OA
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Alternative for those unable to tolerate systemic
therapy
$$$$$
Hyaluronate Injections
Tramadol
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MOA: Weak μ opiod agonist
Efficacy ~ NSAIDS for hip / knee
Preferred to other opioids
Many formulations available
 Co-formulated with
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APAP
Avoid in patients with:
 Comorbid seizure disorders
 Addictive
behavior patterns
Narcotic Analgesics
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Alternative to those refractory to other
treatment modalities
Many, many formulations
Adverse Effects:
 GI:
N/V, constipation
 Somnolence
 Confusion / increase fall risk in elderly
 Abuse potential
Question about K.W.
What would you recommend for K.W.?
Summary
Maximize non-pharmacologic
treatment modalities discussed
 Tailor treatment to patient
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 Symptom
severity
 Medications tried
 Patient expectations and preferences
References
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Altman R, Barkin RL. Topical therapy for osteoarthritis: clinical and pharmacologic
perspectives. Postgrad Med 2009 Mar; 121(2): 139-147.
Bingham CO, Smugar SS, Wang H, Tershakovec AM. Early response to COX-2 inhibitors as a
predictor of overall response in osteoarthritis: pooled results from two identical trials
comparing etoricoxib, celecoxib, and placebo. Rheumatology. 2009 Sep;48(9): 1122-7.
http://www.cdc.gov/arthritis/index.htm (accessed 3/7/2010)
http://www.rheumatology.org/practice/clinical/guidelines/oa-mgmt/oa-mgmt.asp
(accessed 3/7/2010)
Lane NE. Clinical practice: Osteoarthritis of the hip. NEJM 2007 Oct 4;357(14): 1413-21.
Scanzello CR, Moskowitz NK, Gibofsky A. The post-NSAID era: what to use now for the
pharmacologic treatment of pain and inflammation in osteoarthritis. Curr Pain Headache
Rep 2007 Dec;11(6):415-22.
Y Zhang, Jordan JM. Epidemiology of osteoarthritis. Rheum Dis Clin North Am. 2008
Aug;34(3):515-29.
QUESTIONS?
Management of Osteoarthritis