First MTP Osteoarthritis
Hallux valgus
with bunion
OA is a Problem with the Cartilage!
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
Risks for OA
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•
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Advanced Age
Female
Genetics
Obesity
Occupation (overuse)
Trauma
Osteoarthritis: Laboratory
• All laboratory investigations should be normal in
osteoarthritis
• Labs and Xrays are not necessary to make the
diagnosis
Osteoarthritis: Management
• Non-Pharmacologic
– Exercises
– Strengthening
– Splinting
• Pharmacologic
– Oral Medications
Surgery
– Topical Medications
– Injectable Medications
– Alternative/Complimentary Choices
Goals of Treatment
1. Pain Reduction
2. Improved Function
3. Changes the
Disease Outcome
4. Low Cost
5. Low Side Effects
Proper Footwear
Strength Training
Assistive Devices
Physical & Occupational Therapy
Education
Exercise & Weight Loss
Topical Medications
1. Capsaicin
2. Topical Non-Steroidal Anti-Inflammatory
Drugs (NSAIDs)
Pennsaid, Diclofenac
Topical NSAIDs
Limited Use for Osteoarthritis
• Small effects in clinical trials
• Apply 4 times per day
• Expensive
• Messy
Benefits
• Little systemic absorption
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
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
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
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
Oral Medications
1. Simple Analgesics
2. Non-Steroidal Anti-Inflammatory
Medications (NSAIDs)
3. Narcotic Analgesics and non-narcotic
(tramadol)
4. Complimentary Therapy
(Glucosamine)
Acetaminophen
• Acetaminophen (Tylenol )
• Useful in mild to moderate osteoarthritis
Pros
• Cheap
• Safe
• Proven Benefit
Cons
• Small effect
• Often need 3g/day
Non-Steroidal AntiInflammatory Drugs (NSAIDs)
• Traditional NSAIDs
• COX-2 Selective NSAIDs (COXIBs)
Prostaglandin Synthesis
Cell Membrane
Phospholipids
Arachidonic Acid
NSAIDs
COX-1
Prostaglandins
COX-1 Continuously
Expressed
GI Tract
Platelets
Endothelium
Kidney
NSAIDs
COX-2
Prostaglandins
COX-2 Upregulated
Synovial Lining
Macrophages
Chondrocytes
Endothelium
Macula Densa
Non-Steroidal AntiInflammatory 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)
NSAIDs & COXIBs: What Works
• NSAIDs consistently outperform
acetaminophen in OA treatment
NSAIDs & COXIBs: What to
look out for
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GI Risk – gastric and duodenal ulcer
Renal Risk – raise creatinine and HTN
Cardiovascular Risk - ?increased MIs
Hepatoxicity
Edema
Allergic reactions
Clinical Risk Factors for NSAID
Gastropathy
1.
History of Ulcer Related Complications
•
2.
3.
4.
5.
6.
7.
8.
13.5%
Previous ulcer, bleeding
Multiple NSAIDs
High-dose NSAIDs
Concomitant Anticoagulation
Age > 69
Age > 59
Concomitant Steroids
History of CV disease
9.0 %
7.0 %
6.4%
5.6%
3.1%
2.2%
1.8%
More Patients are Without
Appropriate Gastroprotection
Patients >65 years not receiving gastroprotective
approaches with their NSAIDs (%)
100
No gastroprotection
80
60
40
20
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Singh G, et al. Gastroenterology 2006; 130(Suppl. 2): A-82 (Abstract 564).
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
Narcotics
• Benefits
– 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
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;41:1603-12.)
• 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.)
Glucosamine: The Theory
• Glucosamine is a component of cartilage
• Glucosamine is reduced in osteoarthritic
cartilage
• Replacing glucosamine may have
beneficial effects
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
Glucosamine: Practicality
• Dose: 500 mg three times daily
• If no effect after 3 months stop
? Take with chondroitin
Seems very safe
Surgery for Osteoarthritis
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
Surgery: Why Consider
Consider surgery before:
• Advanced muscle weakness
• Joint deformities
• Significant loss of function with further
deconditioning
Treatment Conclusions
• Non-Pharmacologic Therapy
– Education
– Physical Therapy
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Assessment
Education
Strengthening
Range of Motion
Joint Protection & Energy Conservation
Weight Loss & Nutrition
Cardiovascular Exercise
Shoes & Insoles
Assistive Devices
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
Treatment Conclusions
Lack of Scientific Evidence for
• Acupuncture
• Magnet Therapy
OA Guidelines
Other
• Exercise
• Brace, Taping
• Weight Loss
• Joint replacement
Medications
• Acetaminophen
• NSAIDs/Coxibs
• Topical agents
• Injectable agents
Questions