Module 1.2.2 (Management of OA)

Question 1

What are the signs and symptoms of OA? What are the most commonly affected joints?

Answer 1

• Gradual onset, involving few joints
• Most commonly affects DIP, PIP,first CMC joints, knees, hips, cervical and lumbar spine
• Unilateral
• Joint pain- worsened by activity, relieved by rest
• Limited morning stiffness
• Reduced joint movement and crepitus –> crackling noise when joint is moved
• Joint swelling
• Bony enlargement:

> Herberden’s nodes (on DIP)

> Bouchard’s nodes (on PIP)

Question 2

How to diagnose OA? Why are X-rays and blood tests not used for diagnosis? What other purpose do X-rays and blood test have in OA?

Answer 2

Diagnosis often based on history, symptoms and physical examination of affected joint(s)

• X-ray and blood fests not used for diagnosis as the results do not change management or treatment
• Blood test helpful if DR wants to rule out RA
• X-ray used for uncertain diagnosis and exlude other joint disorders

Question 3

Difference between OA and RA:

A) Age of onset

B) Distribution of joints

C) Joint affected

D) ESR (marker of inflammation)

E) Rheumatoid factor

F) Systemic symptoms

Answer 3

A)

OA: later

RA: younger

B)

OA: unilateral

RA: symmetrical

C)

OA: DIP, PIP, first CMC joints, knees, hips, cervical and lumbar spine

RA: PIP, MCP, MTP; DIP joints spared

D)

OA: Normal or elevated

RA: Elevated (due to being an autoimmune disorder)

E)

OA: Absent

RA: Present (due to being an autoimmune disorder)

F)

OA: Absent

RA: Present (extra-articular symptoms)

Question 4

What are the aims of treatment in OA?

Answer 4

• Reduce pain
• Increase mobility
• Reduce disability

Question 5

What are the aims of non-drug treatment in OA?

Answer 5

• Weight reduction „
• Physiotherapy, exercise, hydrotherapy „
• Rest „
• OT „
• Self management strategies

Question 6

What are the THREE main types of drug treatment used in OA?

Answer 6

1. Paracetamol or topical NSAIDs or topical capsaicin
2. Oral NSAIDs
3. Intra-articular injections (injection into joints affected by OA)

Question 7

What is the dosage for 1. Paracetamol or topical NSAIDs or topical capsaicin used in OA

Answer 7

Paracetamol ƒ

• Limited pain relief if used alone in tx of OA (variable between individual) ƒ
• Dose: 1g qid or 1330mg SR tds

Topical NSAIDs

• Include diclofenac, ibuprofen and piroxicam
• To be applied up to 4 times daily

Topical capsaicin

• To be applied up to 4 times daily

Question 8

When is 2. Oral NSAIDs used in OA?

Answer 8

• Moderate to severe OA
• Superior to paracetamol

Question 9

For 3. intraarticular injections (steroids);

A) How long do they provide relief for in knee OA

B) Name FOUR examples

C) Max number of injections administered into a single joint in a year?

D) When to stop using injections

Answer 9

A)

• Short term pain relief - a single injection provides up to 8 weeks (4-12 weeks) relief in pain in knee OA

B)

• Includes triamcinolone, betamethasone, dexamethasone, methylprednisolone

C)

• No > 4 injections should be administered to a single joint in a year

D)

• Avoid further injections if there is no response after two consecutive injections

Question 10

For 3. intraarticular injections (hyaluronic acid);

A) How is it given

B) What does it do? How long does its effects last?

C) Comparison to intraarticular corticosteroid

Answer 10

A)

• Given as a single injection or as a weekly injection for 3 to 5 weeks depending on the formulation

B)

• Relief pain, swelling, and stiffness up to six months in knee OA

C)

• Expensive and slower onset of action but longer duration of pain relief compared to intraarticular corticosteroid

Question 11

For 3. intraarticular injections (regenerative);

A) What is it?

Answer 11

• platelet-rich plasma (PRP), adipocyte cell suspensions or mesenchymal stem cell injections

Question 12

What are the two complementary medicines used in OA? Provide details such as doses and cautions.

Answer 12

​Glucosamine

• Dose: 1.5g daily (available as sulfate or HCl salt)
• Sulfate salt shown to be more effective
• Conflicting evidence on efficacy

Caution:

> Shellfish allergy „

> Impaired glucose tolerance „

> Anticoagulant tx (affects INR)

Chondroitin

• Dose: 800-1200mg daily
• Shown to be as effective as glucosamine

Caution:

> Antiocoagulant Tx (affects INR)

Question 13

When is surgery (arthroplasty) used for OA?

Answer 13

• Do not respond to other tx
• Function in the joint significantly impaired
• X-ray evidence of joint damage

> Mostly indicated for hip and knee OA

Question 14

Provide an outline/algorithm of the Tx in OA starting off with non-pharmacological management

Answer 14

1. Non pharmacological management +
2. Topical NSAIDs or capsaicin (first line) +/-
3. paracetamol 1g orally 4-6 hourly as necessary, upto max of 4g daily OR paracetamol modified-release 1.33g orally, 8 hourly as necessary OR an NSAID orally +/-

> NSAID only if patients at low risk of NSAID

> If at high risk = first-line treatment is topical NSAID/capsaicin + paracetamol

4. IA corticosteroid or hyaluronic acid injection +/-
5. Glucosamine or Chondroitin

Question 15

Provide a summary for OA

Answer 15

• OA is a degenerative joint disease characterised by progressive loss of articular cartilage
• Management of OA include non pharmacological interventions and pharmacological treatment to reduce pain and improve functionality
• Pharmacological treatment include analgesic (paracetamol, oral and topical NSAIDs, topical capsaicin) and intra-articular injections (steroids, hyaluronic acid injection )
• Glucosamine and chondroitin supplementation are shown to reduce pain in certain patients albeit limited evidence
• Surgery can be an option in patient refractive to above treatments