Managing osteoarthritis: What’s best for your patient?

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Applied Evidence

Managing osteoarthritis: What’s best for your patient?

J Fam Pract. 2008 October;57(10):644-649

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References

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Drug therapy: Start with acetaminophen

The OARSI guidelines cite acetaminophen as an “effective initial oral analgesic” for mild to moderate pain in patients with OA of the hips or knees (SOR: 92%).⁴ In analyses conducted by the committee, the NNT to achieve an improvement in pain ranged from 1 to 2 in an earlier systematic review⁸ to 4 to 16 in a subsequent meta-analysis.⁹

FAST TRACK

Recreational, mild-intensity running has little effect on OA risk; high-intensity running increases the risk

Prescribe NSAIDs for short-term relief. While acetaminophen is considered the preferred long-term oral treatment, the strongest pharmacologic recommendation for alleviating the pain and stiffness associated with OA of the hip or knee is for nonsteroidal anti-inflammatory drugs (NSAIDs) (SOR: 93%). The caveat, however, is that NSAIDs should be used in the lowest effective dose and are not considered a long-term option. Patients with increased gastrointestinal (GI) risk should use either a cyclooxygenase-2 (COX-2) agent or an NSAID with a proton pump inhibitor or misoprostol for GI protection.

For those with cardiovascular risks, both nonselective NSAIDs and COX-2 agents require caution; here, too, the lowest dose for the shortest possible duration is recommended.

The guidelines also call for the use of topical agents, such as topical NSAIDs and capsaicin, for relief of symptoms (SOR: 85%). The NNT for topical NSAIDs was 3 (95% CI, 2-4);⁴ capsaicin had an NNT of 4 (95% CI, 3-5) after 4 weeks of therapy.⁴ The recommendations also note that glucosamine and/or chondroitin sulfate may alleviate some symptoms of osteoarthritis of the knee, but should be discontinued if no benefit is observed after 6 months.

When something stronger is needed. For moderate to severe pain that has not responded to oral agents, intraarticular (IA) injections with corticosteroids are recommended, as are IA hyaluronate injections (SOR: 78% and 64%, respectively). Weak opioids/low-dose narcotics round out the recommendations for treating moderate pain, with stronger opioids reserved for patients whose pain is severe.

When to consider surgery

Joint replacement surgery is recommended for patients who do not achieve adequate pain relief and functional improvement from nonpharmacologic and pharmacologic modalities (SOR: 96%). A meta-analysis of 74 studies assessing quality of life 1 to 7 years after total hip and total knee replacement (THR and TKR) found substantial improvement in pain and function, but variable effects on mental health and social functioning. Risk factors for poor outcomes include older age; more (or more severe) preoperative pain; medical comorbidities; musculoskeletal comorbidities such as low back pain, with functional limitations; low mental health scores; and OA in the hip that was not replaced.^10,11

Unicompartmental knee replacement (UKR) had an SOR of 76%. Reviews that compared TKR to UKR found similar 5-year outcomes in knee pain and function. Those who underwent UKR had better range of motion, but prosthesis survival at 10 years was better in those with TKR (>90% vs 85% to 90%).¹²

In young adults, osteotomy and jointpreserving procedures are recommended for hip OA, especially when dysplasia is present. In young, active patients with unicompartment OA, high tibial osteotomies may delay TKR by as long as 10 years.¹³

Joint lavage and arthroscopic debridement in knee OA remain controversial, although they may provide short-term symptom relief (SOR: 60%). Joint fusion as a salvage procedure after failed TKR had an SOR of 69%.

FAST TRACK

For young, active patients with unicompartment OA, osteotomies can delay total knee replacement for up to 10 years

Work as a team to improve outcomes

The inevitable increase in the number of patients with OA of the hips and knees underscores the importance of having a range of treatment strategies, often best delivered by a multidisciplinary team with the family physician at the helm. The OARSI guidelines, which are backed by both a thorough review of research findings and expert consensus, can help you convince patients to take an active role in managing this potentially debilitating condition. Patients’ commitment to lifestyle modifications and self-management, bolstered by your guidance and support, is the most effective way to keep patients with OA on the move.

Correspondence
Greg P. Gutierrez, MD, Associate Professor, University of Colorado Denver Health Sciences Center, Department of Family Medicine, Denver Health and Hospital, 660 Bannock St., Denver, CO 80218; greg.gutierrez@dhha.org.