Transcript Osteoarthritis (OA)

Małgorzata Węgierska
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OA is the most common joint disorder
worldwide. In western countries, radiographic
evidence of this disease is present in the
majority of people after 65 years of age and
in about 80% of people over 75 years of age.
Pain and other symptoms of OA may have a
strong effect on quality of life, affecting both
physical and psychological functions.
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OA is a complex, active degradative and repair
process of cartilage and subchondral bone with a
synovial inflammation.
Several factors are involved in this process such
as mechanical stress, biochemical and genetic
factors.
Chondrocytes respond to injuries by producing
degradative enzymes and by developing
inappropriate repair responses. A lot of prodegradative agents such as proteinases and
proinflammatory cytokines have been extensively
studied and may compromise macromolecular
synthesis, resulting in the development of
cartilage breakdown.
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OA is defined by focal lesions of the articular
cartilage, combined with a hypertrophic
reaction ( sclerosis) in the subchondral bone
and new bone formation ( osteophytes) at the
joint margins.
OA is diagnosed where there is joint pain,
together with characteristic radiographic
changes, in the absence of an alternative
cause.
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Pain is the first predominant symptom of OA. It
occurs after joint use and is relieved at rest. With
disease progression, pain occurs with minimal
motion or even at rest and finally, even during
sleep.
Because cartilage has no nerve supply and is
insensitive to pain, the pain in OA must arise
from non-cartilaginous structures such as
periost, intra-articular ligaments, pressure on
subchondral bone with venous engorgement,
intramedullary engorgement, capsular
distension, alterations of synovium or tendons
and fascia.
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Stiffness may also occur in the morning or
after periods of inactivity during the day.
Morning stiffness generally resolves after <15
min.
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Limitations of motion and function develop as
OA progresses and are related to joint surface
incongruity with reduced joint space, muscle
spasm or diminished strength, leading to
instability and mechanical block from
osteophytes and loose bodies.
Being overweight
Female sex
Oestrogen deficiency
Getting older
Family history
Joint injury
Joints that are not properly formed
A genetic defect in joint cartilage
Stresses on the joints from certain jobs and
playing sports
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Joint enlargement results from joint effusion
and/or osteophytes and/or synovitis.
Joints are usually tender during active motion
testing and under pressure.
Joint deformities and subluxation reflect
advanced disease resulting from cartilage
loss, collapse of subchondral bone,
formation of bone cysts and bony
overgrowth.
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No single test can diagnose osteoarthritis.
Most doctors use several methods, including
medical history, a physical exam, x-rays, or
lab tests.
Plain radiographs are the ‘gold standard ‘ for
diagnosis. Characteristic changes on plain
radiographs: include osteophytes, joint space
narrowing and subchondral changes:
sclerosis and cysts.
OA is typically not associated with high acute
phase response.
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Primary
Nodal (hand)
Erosive (hand)
Generalized ( hand + knee/hip)
Diffuse idiopathic skeletal hyperostosis
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Secondary
Metabolic ( acromegaly, ochronosis,
haemachromatosis)
Traumatic (major joint trauma, joint surgery,
chronic injury)
Inflammatory ( any inflammatory arthropathy,
septic arthritis)
Neuropathic ( diabetes mellitus)
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The hand is one of the most common sites of
OA. Bony enlargements of the proximal
interphalangeal joints are called Bouchard’s
nodes, whereas those of the distal
interphalangeal joints are called Heberden’s
nodes.
Erosions of the interphalangeal distal joints
on x-ray examinations are prominent
features in a subset of patients with OA called
‘erosive OA’.
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Psoriatic arthritis
Gout
Rheumatoid arthritis
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Education about the disease and effective
treatments.
Exercise therapy should include both
aerobic conditioning and strengthening
exercise.
Weight loss advice for all who are
overweight or obese.
Hot and cold packs can be helpful for acute
exacerbations of joint pain.
Transcutaneous electrical nerve stimulatin (
TENS) may give safe and effective pain relief
in some patients with OA, and is
recommended as a safe adjunctive modality
in the majority of guidelines.
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Paracetamol is preferred as first line
analgesia, because of its favourable safety
profile.
Non-steroidal anti-inflammatories (
NSAIDs) provide additional symptomatic
benefit in some patients.
Gastrointestinal and cardiovascular risks
must be considered befor use NSAIDs. They
should be avoided in patients with
established ischaemic heart disease or
cerebrovascular disease, and used with
caution in those with risk factors for these
conditions.
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Current European recommendations for
prescribing NSAIDs in patients at increased
risk of gastrointestinal toxicity are to use a
COX-2 selective agent or a non-selective
NSAID plus a proton pump inhibitor (PPI) for
gastroprotection.
Opioids, such as codeine or higher strength
opioids may be needed.
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Certain topical NSAID preparations are
effective.
Topical capsaicin – this is a lipophilic
alkaloid derived from chilli peppers. Topical
capsaicin applied three times daily can
reduce pain associated with hand or knee
OA. Capsaicin has a high rate of skin
reactions.
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Intra-articular injection of corticosteroid is
helpful for quick control of pronounced pain
from knee osteoarthritis, thumb base and
other joints. Corticosteroid injections can
give short-term relief ( 2-3 weeks) in knee
and as long as 3-4 months in hip.
There is little compelling evidence for the
efficacy of intra-articular Hyaluronan.
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However, the main goal of OA therapy should be to
delay cartilage degeneration and even help to
regenerate the cartilage structure.
Medications having these properties are generally
called ‘chondroprotectives’.
They are diffrrentiated as symptomatic slow acting
drugs in OA ( SYSADOA) and disease-modifying OA
drugs ( DMOAD).
Currently, glucosamine and chondroitin are the two
most commonly used SYSADOA to modify the
clinical and radiological course of OA.
Glucosamine and chondroitin are also the most
frequently used nutraceuticals in humans as well as
in animals to alleviate pain associated with
arthritis.
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There are currently no universally accepted
disease-modifying OA drugs. Single studies
have suggested efficacy for a number agents
and toxicity has prevented development of
others. Potential DMOADs include:
Diacerein
Doxycycline
Licofelone
Strontium ranelate
Bisphosphonates
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Surgery, including total joint replacement,
should be considered for patients who have
persistent pain, stiffness, and reduced
function that are refractory to non-surgical
treatments and which impact significantly on
their quality of life.
Patient specific factors such as age, obesity
or other comorbidity should not be barriers
to surgery, and referral should be made early
before there is prolonged and established
functional limitation and serere pain.