Guidelines for treating osteoarthritis

Summarized by Robert W. Griffith, MD
September 28, 2000 (Reviewed: January 15, 2003)

Introduction

Osteoarthritis (OA) is the most common form of arthritis in older persons, chiefly affecting the knees or hips; regrettably, it's responsible for a great deal of pain and suffering. New treatments are being suggested every day, and the American College of Rheumatology has done physicians and patients a great service by updating its guidelines for managing the disease. They have taken a fairly conservative approach, so that their recommendations are based on reliable information obtained from well-conducted clinical trials as well as the views of expert rheumatologists.

Non-drug treatment

Well-informed patients are able to undertake self-management programs that can be very effective in helping with pain and limitation of activities, so that their quality of life is also improved. Self-management courses are held in most countries, under the auspices of national Arthritis Foundation branches, or the Arthritis and Rheumatism International (ARI).
If someone with OA is overweight, a change in diet is necessary. It has been clearly shown that loss of body fat leads to an improvement in symptoms. Appropriate exercise programs (aerobic exercise, range-of-movement motion and muscle-strengthening exercises), as well as heat treatment routines, should be designed for the individual sufferer. Quadriceps exercises are very important. Appropriate assistance devices (e.g. canes, crutches, walkers) allow people to get about better. Footwear must be checked, and if necessary replaced, by a trained specialist.

Other treatments

Any drug treatment should be regarded as an addition, not a replacement, to the non-drug steps outlined above. A simple painkiller, such as acetaminophen, is effective for mild pain.

A trial can be made of methylsalicylate or capsaicin cream applied to the affected joint several times a day. Either creams are likely to produce a burning sensation, but this doesn't usually lead to stopping their use.

If the pain is moderate to severe or there are signs of inflammation (redness, warmth, or joint swelling), a non-steroid anti-inflammatory drug (NSAID) is the next logical step. However, before a drug of this type is prescribed, the physician must review whether there are reasons not to use one. About 20 - 30% of all hospitalizations for stomach ulcers in the USA have been attributed to NSAID treatment, and there is no doubt that this type of drug (e.g. ibuprofen, naproxen) can cause ulceration or bleeding, especially in people with previous gastric trouble and in those over 65. NSAIDs are also associated with kidney toxicity. The physician will determine whether an NSAID is safe for a given patient, or whether a more expensive alternative should be used - one of the so-called COX-2 inhibitors.

The available COX-2 inhibitors are celecoxib and rofecoxib; others will follow soon. They are equally effective as NSAIDs but they are less likely to cause stomach trouble, although they can produce kidney toxicity. They are much more expensive than NSAIDs.

An alternative to using a COX-2 inhibitor is to take an NSAID together with a drug to protect the stomach lining - omeprazole, for instance. Another option is a stronger painkiller from the opium family - tramadol. This is as effective as an NSAID, but causes nausea, constipation, and drowsiness; fortunately, it's doesn't produce addiction. In extreme cases, severe pain may require a combination of acetaminophen with codeine or another opium derivative, dextropropoxephene. The risk here is of tolerance and dependency (i.e. addiction), as well as some suppression of respiration, which may lead to chest infections.

Injections into the joint

Injections of a derivative of hyaluronic acid, hyaluronan, can relieve pain in knee OA. The relief obtained is equivalent to that from an NSAID. (This treatment is not recommended for hip OA.) There may be some pain at the injection site, and/or joint swelling. Almost similar pain relief is achieved by injections of a glucocorticosteroid drug (a 'steroid') into the joint. The effect of a steroid injection is quicker, but doesn't last as long as that of hyaluronan.

Surgical treatment

If someone has continued pain and disability that doesn't respond to appropriate exercises and drugs, and day-to-day activities are limited, they should go to an orthopedic surgeon for assessment. Replacement of the joint (arthroplasty) provides marked long-term pain relief and improvement in function in most cases, but this is largely dependent on a strenuous rehabilitation program.

Other treatments

Newer treatments, such as oral glucosamine and chondroitin sulfate, have been widely studied - and widely advertised. To date, the American College of Rheumatology does not recommend their use, as not enough well conducted clinical trials have been reported in sufficient detail to allow definite conclusions about their safety and efficacy. Similar reservations apply to the use of procedures such as pulsed electromagnetic fields and lasers, acupuncture and dietary supplements of various kinds. Well-conducted clinical studies of some of these are underway, and we should know more about them fairly soon.

Comment

The American College of Rheumatology has done performed a useful service in updating its recommendations for managing osteoarthritis. There are already many ways of treating the condition, so that the individual sufferer should not feel dispirited. The speed of clinical research in this area is such that one can hope for several important breakthroughs by the time a new set of guidelines is prepared.

Vioxx (rofecoxib), a COX-2 anti-inflammatory drug, has recently been withdrawn from all world markets by Merck, its manufacturer. Merck found that there was an increased risk of heart attack or stroke for people taking a standard dose (25 mg per day) for 18 months or more. The risk of such problems was twice that of people taking a placebo. However, someone's risk of having a heart attack or stroke is relatively low; double the risk means the chance of such an event is still "small," according to the USA Food and Drug Administration (FDA). Celebrex (celecoxib) and Bextra (valdecoxib) are other prescribed COX-2 inhibitors. Studies have so far indicated that only Vioxx poses a risk of heart problems. The FDA will examine the other two drugs to see if there is any cause for concern. Robert Griffith, Editor.

Source

• Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee: 2000 Update. RD. Altman, MC. Hochberg, RW. Moskowitz, TJ. Schnitzer, Arthritis & Rheumatism, 2000, vol. 43, pp. 1905--1915

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