1. First MTP Osteoarthritis
Hallux valgus with bunion

2. OA is a Problem with the Cartilage!

3. 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

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

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

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

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

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

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

10. 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

11. 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

12. 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

13. 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

14. 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

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

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

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

18. 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

19. 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)

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

21. 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

22. Clinical Risk Factors for NSAID Gastropathy
History of Ulcer Related Complications 13.5%
Previous ulcer, bleeding
Multiple NSAIDs %
High-dose NSAIDs %
Concomitant Anticoagulation 6.4%
Age > %
Age > %
Concomitant Steroids %
History of CV disease %

23. 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).

24. 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

25. 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

26. 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: )
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.)

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

28. 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

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

30. Surgery for Osteoarthritis

31. 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

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

33. 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

34. 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

35. Treatment Conclusions
Lack of Scientific Evidence for
Acupuncture
Magnet Therapy

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

37. Questions