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

• 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

Physical & Occupational Therapy

Assistive Devices

Proper Footwear

Exercise & Weight LossEducation

Strength Training

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

yearCons• 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 osteoarthritisPros• Cheap• Safe• Proven BenefitCons• Small effect• Often need 3g/day

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• Traditional NSAIDs• COX-2 Selective NSAIDs (COXIBs)

Prostaglandin SynthesisCell Membrane Phospholipids

Arachidonic Acid

Prostaglandins Prostaglandins

COX-1 Continuously Expressed

GI TractPlateletsEndotheliumKidney

COX-2 UpregulatedSynovial LiningMacrophagesChondrocytesEndotheliumMacula Densa

COX-2COX-1NSAIDs NSAIDs

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)

NSAIDs & COXIBs: What Works

• NSAIDs consistently outperform acetaminophen in OA treatment

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

Clinical Risk Factors for NSAID Gastropathy

1. History of Ulcer Related Complications 13.5%• Previous ulcer, bleeding

2. Multiple NSAIDs 9.0 %3. High-dose NSAIDs 7.0 %4. Concomitant Anticoagulation 6.4%5. Age > 69 5.6%6. Age > 59 3.1%7. Concomitant Steroids 2.2%8. History of CV disease 1.8%

More Patients are Without Appropriate Gastroprotection

Singh G, et al. Gastroenterology 2006; 130(Suppl. 2): A-82 (Abstract 564).

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

No gastroprotection

Year

100

80

60

40

20

0

Patients >65 years not receiving gastroprotectiveapproaches with their NSAIDs (%)

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

• 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