Osteoarthritis Flashcards
Learning outcomes
Arthritis and specifically osteoarthritis. We’ll be looking at defining what arthritis generally actually is and then specifically focusing on osteoarthritis will be looking at the impact of osteoarthritis on the population, thinking about the pathological changes in osteoarthritis and then looking at the risk factors and causes of osteoarthritis. We’ll think about how it’s diagnosed and then of course, we’ll look at the pharmacological and non-pharmacological treatment options as well.
What is Arthritis disease?
Let’s define arthritis. This is an image of a kind of a typical healthy synovial joint. Throughout this screencast and two or three others, you’ll be looking at different types of arthritis, so just to give you a general overview of what this actually means.
Arthritis is a term used for when there is evidence of joint inflammation including swelling, deformity, and pain. This could be in single or multiple joints. Most types of arthritis are long term conditions, but there are multiple different causes some include autoimmune responses. Why do we care about arthritis in pharmacy? Around 10 million people in the UK have thought to have arthritis, just general arthritis heading generally well known forms of arthritis, are more common in older people say there’s often that kind of preconception that it does not affect children, but it can actually affect people of all ages, even children and teenagers. The pain caused by arthritis can make life really challenging, and it can make it harder to get about the symptoms of arthritis. I’m very from week to week and even from day-to-day and be unpredictable. Various forms of arthritis can present over the counter in Community pharmacy and other forms may need hospital consult involvement as well due to the kinds of medication we might use. Its therefore really important that you have a good understanding of these conditions.
Synovial joint is the most common and most movable joint in the body. The skeleton is kind of held apart by this cavity and I’ve included the image there of a typical healthy joint. As you can see. So, you’ll notice the joint is surrounded by this capsule filled with a thick fluid, synovial fluid that helps to lubricate the joint.
These capsules help to hold the bones in place, and they do that with the help of the ligaments and all the muscles and things like that. The ends of the bones within the joint align with cartilage, which is smooth but tough layer of tissue that allows bones to glide over one another as frictionlessly as possible when you move. So, if you want to move a bone, your brain will give the signal to a muscle which then pulls a tendon, and this is attached to the bone. So, the muscles have that important role in supporting the joint as well. So that’s our healthy joint.
What is Osteoarthritis?
Osteoarthritis is the most common form of arthritis, but osteoarthritis is not an autoimmune disease. So, as I’ve mentioned before, arthritis generally fits into the autoimmune diseases because of things like rheumatoid arthritis. We are including osteoarthritis here for completion, but it is not an autoimmune disease.
NICE defines osteoarthritis as a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. Osteoarthritis is what used to be called kind of wear and tear arthritis, as it was thought to be caused by just getting old but we now know it’s more complicated than that, it’s not this passive process that will simply worsen as you age, regardless of who you are, what you do. It is, however, the most common musculoskeletal condition in older people.
It’s the disorder of the joints and ongoing damaging processes caused by loss of cartilage at the joint or articular cartilage, followed by response in the body to try and repair the damage, which can then in turn make things worse and also cause damage to the periarticular bone or other bone in that joint.
Osteoarthritis can affect any synovial joint, but most commonly affects the knee, hip, spine and small joints in the hands and fingers. The extent of the damage does not correlate to the extent of the pain the patient might feel, so that’s really important and X-ray could show minimal damage, but the patient could report strong feelings of pain and vice versa and it can be found in, in weight bearing and non-weight bearing joints and because the non-weight bearing joints might be used very frequently so the damage could come in that way.
Epidemiology?
Now let’s think about the impact of osteoarthritis. It was estimated in 2013 that around 8.5 million people in the UK aged 45 years and over have seen a doctor for osteoarthritis. Obviously, that was a little while ago now, and it’s likely that with an increasing age and increasing population and also the increased availability of over the counter medication and kind of general under reporting as well that this number has risen and because some people just see it as a condition of getting old, they won’t tell anyone that they haven’t having problem. The risk of developing osteoarthritis increases with age. A third of women and almost a quarter of men between 45 and 64 have sought treatment for osteoarthritis of some kind, and this rises to almost a half of people aged 75 and over. the prevalence of osteoarthritis is generally higher in women than men, but the difference is most apparent for hand and knee osteoarthritis and among people of around 50 years old and over. Woman accounted for roughly 60% of hip and knee replacement operations in the UK in 2017 and over 90% of those were due to osteoarthritis.
Impact and comorbidities?
Common comorbidities, women, and men over 65 years of age who have osteoarthritis are at 17% and 15% increased risk of hospitalization for cardiovascular disease and about 20% of people with osteoarthritis experience symptoms of anxiety and depression and that could be obviously due to the pain that they’re feeling worries about going out and doing their daily activities.
There’s also a massive impact on the quality of life and the ability to work, so obviously with pain and that’s massive. So nearly three quarters of people with osteoarthritis reports, some form of constant pain with one in eight describing their pain is often unbearable. Having more than one co-morbidity contributes to worse pain and performance based physical function in people with knee and or hip hop osteoarthritis. A third of people with osteoarthritis retiree early give up work or reduce the hours they work because of their condition, so huge impacts on our society as a whole.
Pathophysiology?
In osteoarthritis, the whole of the joint is involved due to trauma, whether that’s aging or other known factors, there is damage to the cartilage in some way. The rate of damage then begins to exceed the rate of repair and so this leads to degeneration of the bone and cartilage. When the cartilage cells are injured, this sets off an inflammatory response and production of the pro inflammatory mediators. So, if you want to know more about this you might want to look back at Anja inflammation screencast.
As the cartilage is damaged more of the joint fails to dissipate the joint load effectively, which then causes further damage to the whole joint so the worse it gets it then becomes more and more difficult for the bone to support itself.
Eventually the actual bone becomes exposed more and more, attempts by the body to repair the joint causes cartilaginous growth at the edge of the joint, which can become calcified and causing these things called osteophytes or Bernie spurs the continuity of the Pro-inflammatory mediators and the catabolic enzymes become ultimately lead to complete cartilage destruction.
The underlying bone will have a polished, smooth appearance or a berniation, which is kind of an unusual Ivy like hardness in areas where it’s in direct contact with another bone and multiple loose bodies can be present within the joint space. This all ends with a narrowing of the joint space causing sinusitis, which is a painful and tender inflammation of the synovial lining of joint and effusion, which is the swelling of the joint as well.
There’s a couple of pictures here which hopefully just explain this process a little bit more.
What are the risk factors and causes of osteoarthritis?
Osteoarthritis can be either primary or secondary.
Primary is when it’s idiopathic, so the exact cause is unknown. There’s damage to the cartilage from somewhere, and in secondary there is a specific cause? So probably previous injury to a joint and there might be a congenital abnormality for example, people with an abnormal hip shape caused by developmental problems or at an increased risk of developing osteoarthritis and also if they have any inflammatory arthritis conditions, not osteoarthritis, they’re going to be an increased risk, things like gout or rheumatoid arthritis, leave them then prone to developing osteoarthritis secondary to that.
There are a few risk factors: age, we’ve mentioned that kind of typical thought process of it being wear and tear, that may well be a factor, but it’s also potentially linked to reduction in growth hormones as we age. So, repair is slower and there may also be a reduction in muscle strength so there’s less support for the joint to be held apart.
Being female is a risk factor and it suggested that it’s perhaps due to the drop of estrogen levels around menopause and that’s why it’s responsible for the higher prevalence in women as they get older and some research has shown hormone replacement therapy may slow or delay the onset of osteoarthritis, but it doesn’t really show prevention of the progression of the disease. There is obviously a lot of risks around using HRT like lots of side effects and cautions we need to consider and weigh up. So, there’s loads more research be done in this area, very unlikely to HRT being used in osteoarthritis at this point.
Being obese, a BMI over 25 as an increased risk, so the risk of developing osteoarthritis throughout life increases with the rising BMI and people who are overweight or obese or approximately 2.5 to 4.6 times more likely to develop knee osteoarthritis than those of a normal body weight. You think about the extra weight, the extra pressure that’s putting on the joints could be one of the causes of the damage.
Occupation could be a risk if it’s physically demanding. So knee Osteoarthritis is more frequently observed in people with occupations that request squatting and kneeling. Hip osteoarthritis is also associated with prolonged lifting and standing and hands osteoarthritis more frequent in people with occupations requiring increased manual dexterity.
There is an estimated heritability of 40-65% depending on the joint site, so genetic factors account for about 60% of hand and hip osteoarthritis and 40% of knee osteoarthritis. Is very unlikely that there’s a single gene that we can pinpoint to determine the genetic risk, but it’s more likely that it’s going to be a multiple variety of genes involved and the genes that have been examined so far are responsible for the makeup of joint tissues and different things like that, but also it’s probable that they’ll be genes that are involved, which would help determine joint shape, muscle strength, things like body weight. There all of those genes are also going to play probably important roles as well. Again, more research is needed there.
I’m just wanting to mention as well, there is no current validated tool to help predict whether or not someone is going to develop osteoarthritis or not. So, we have no real kind of way of evaluating a patient. All we can do is try and reduce risk factors to mainly being overweight essentially.
How is osteoarthritis diagnosed?
First of all, we’ve got the basic signs and symptoms. So basic signs and symptoms of osteoarthritis are activity related Joint pain, it’s worsening the more the joint is used, and the patient may have some morning stiffness, but this will not typically last longer than 30 minutes. Some patients might present with some muscle wasting around that area due to not moving the joint to prevent pain, but normally patients will have seen a healthcare professional by then. Be aware that hip pain could present in different areas of the thigh, including in the groin, and so the patient may not be aware it’s actually stemming from the hip. The knee joint is obviously used frequently throughout the day, so the pain often worsens as the day goes on and osteoarthritis in the hands can present as nodes which are visible, so you can see and the picture there, so they’re visibly hard boney swellings at those distal interphalangeal joints at the end of the fingers, and they’re formed from the osteophytes. Do you remember that osteoarthritis can present in one or multiple joints, so it may be representing a couple of different locations, but it might just be one. So just because it’s not spread over the body, you know it could just be the fingers. It could just be in the knee and just make sure that that’s on your radar.
Nice recommends diagnosis without any specific investigation. So, this is because there’s that poor correlation, I mentioned earlier about the damage shown on X-rays and things and the pain the patient is actually experiencing symptoms. So as long as they have that activity related joint pain and either no morning stiffness or short lived, morning stiffness in the joints and they’re over 45 years old a diagnosis would be made, and normally by the GP.
Sometimes you may have blood tests and X-rays to rule out other conditions or things like gout or rheumatoid arthritis. If there are any other symptoms that are potentially causing alarms. If there’s anything that’s a bit unusual not typical for osteoarthritis, there may use those kind of blood tests or x-rays to rule that out. For example, things like a hot swollen joint might indicate something different or prolonged morning stiffness, or if there’s been a history of trauma then they might look at other conditions or other reasons for that pain.
What is the treatment?
Treatments
This image here in the NICE guidance and it’s a really nice image.
It’s important when we’re considering the management of osteoarthritis that we consider the patient as a whole, osteoarthritis can have a huge impact on the patient because of the pain and stiffness they experience a person’s quality of life, sleep, ability to work and do hobbies, their mood and the impact on their relationships need to be carefully managed. The NICE guidelines diagram enables you to just fully capture the full impact of osteoarthritis on patients.
The lifestyle changes that I’m now going to mention are really important because they’re going to help to slow or even stop the pression of osteoarthritis if a patient is overweight or obese, then offering help to achieve weight loss is essential. It’s going to help reduce the burden on the joints. So that’s the first thing exercises the core treatment of osteoarthritis recommended by NICE. It’s important to add in local muscle strengthening and general aerobic exercise, because this will help reduce pain and inflammation and it should be recommended to all patients irrespective of their age, their pain level, and any disabilities then they have or any other comorbidities they have. Stretching the muscles could also be helpful. Different types of exercises you can find on the versus arthritis website which again I’ve referenced at the end so you can look on there and obviously GPS may well make referrals to physiotherapists and things like that if needed.
Physical aids can be used, so good quality footwear which includes shock absorbing properties might help ease pressure on hip and knee joints, braces or splints on the affected joint can also help give support things like walking sticks or wheeled walkers can be helpful if a person’s ability to undertake specific activities has been limited. and you just need to be careful about the way you’re talking to people especially when you’re thinking about introducing these types of aids, because there may be kind of not wanting to feel like they need to use them, so you really need to be patient word here.
There is specific joint protection, which is kind of avoiding ripping in certain ways, it can damage the joint more, for example, that sort of thing can be really helpful and tips about that again can be found on the arthritis website as well and there are loads of different aids available to purchase which can help with day-to-day tasks. So, things that help you grip kind of bottle tops or jar lids and so that you’re not having to use the strength in your hands and putting extra pressure on the joints, all this there’s loads of different things that just really help, and with those tasks. So having a range of products available, for example in the Community pharmacy is quite common so that people can kind of explore them and look at them without any pressure and you can obviously be there to help guide if necessary.
There is no specific treatment currently available for osteoarthritis in terms of pharmacological treatment and it’s not possible to reverse the effects.
The pharmacological treatments we can offer is centered around kind of this symptomatic pain relief and the pain relief is an adjunct to lifestyle changes, not instead of so we would always be recommending that core exercise as first line and then thinking about how we help with the pain relief. start with using topical NSAIDS for a trial of at least four weeks, ensuring it adherence is good. Also reminding the patient that the effects might not be immediate, so they need to continue using it for the full trial.
Topical NSAIDS can be used with paracetamol or, so regular dating of that can be offered alongside the topical NSAIDS. Alternatively, the patient could try a topical capsaicin cream, so capsaicin is derived from the capsicum extract, which comes from the pepper family of plants. It works mainly by reducing substance P, which is a pain transporter in your nerves. 0.025% cream is licensed for the management of osteoarthritis, but it seems to have no real major safety problems, so it’s a nice choice for patients, especially if they’re on a multitude of kind of medications or have other comorbidities.
It is important that the cream is applied at regular intervals up to four times a day, and this will help to ensure that the patient gains tolerance to the burning sensation. There can be associated with initial use of capsaicin. Relief of pain usually starts in the first week of treatment and builds gradually if the cream is applied frequently and those two can be used with paracetamol and so again, we would use that alongside. If these combinations aren’t effective,
we can consider switching from a topical to an oral NSAIDS That might be necessary and as NSAIDS would be taken regularly don’t forget it’s important to co-prescribe a proton pump inhibitor alongside this to help protect the stomach.
The patient could use the topical capsaicin cream, oral paracetamol or an oral NSAIDS altogether as well that’s another option.
If the patient is taking low dose aspirin and then we may consider an oral opioid analgesic instead of an oral NSAID depending on the patient’s risk factors also if they were unable to tolerate NSAIDS to whatever reason. If paracetamol and oral NSAIDS wasn’t enough for pain relief you, you could also consider adding a low dose opioid.
The thing to be really careful with opioids and especially in osteoarthritis is often these patients are older people, they may be elderly and actually we need to use caution and with opioids in the elderly because of the side effects of things that constipation and the risk of sedation and falls and things. Although it is an option, it’s one that we would try to avoid, and we would tend to stick with the paracetamol and oral NSAIDS as much as possible.
In osteoarthritis and we can use intra articular injections, so injecting into the joint space of corticosteroid and injections into the joint could relieve inflammation and reduce pain and disability. So that is a possible option that would normally be kind of be done, you wouldn’t normally see that kind of regularly within the Community pharmacy and you’re not going to be doing prescriptions that. The injections can be considered as adjuncts to the cool treatment in later stages of osteoarthritis, but it is for the relief of moderate to severe pain. So, this is when it’s gonna, you know, really quite bad as when they would be having those injections. So, you might hear people talking about the fact that they’ve gone for an injection or that they have regular injections of the corticosteroid into the joints, but you’re not necessarily going to see it on a prescription as such. So other things we can consider are things like thermal therapy so using hot and cold and we can also think about transcutaneous electrical nerve stimulation or tens machine and patients might well think come in to try and try these products and buy them over the counter. So, kind of make sure you’re all aware of those options. What we don’t use though is the heat cream so those topical heat creams that you can get, they’re not recommended by NICE in osteoarthritis. And another note, you may well have heard of supplements called chondroitin and glucosamine, sometimes in together and their proposed to provide relief of pain in in osteoarthritis. The reason being that things chondroitin comes from natural sources such as shark and bone cartilage, so it’s kind of the conjoint chondroitin and is found indulgency in cartilage in cartilage tissues anyway, and so it may well serve a substrate for the formation of the joint matrix structure.
There is no statistically significant benefit in the studies of the chondroitin when compared with placebo and glucosamine is another thing that can be used and that’s used in the synthesis of carbohydrate containing compounds found in the tendons, ligaments, cartilage, synovial fluid and things but again, studies have failed to demonstrate a benefit in terms of pain relief or disease modification. So currently NICE are stating that glucosamine, chondroitin product should not be offered at routine for the management of osteoarthritis. Some people may come in and want to buy them, we just have to let them know there is currently a study shows that it’s not statistically significant changes, but obviously it might be something that people are keen to try as they’ve read. Read around it themselves.
Finally, if things are really severe in the joint, then there’s surgery option mainly joint replacements when the symptoms are persistently debilitating despite treatment, so that that might be an option. You might have people having hip or knee replacements and that would be kind of end stage there.
Summary
So just to summarize. There are no pharmacological treatments to help prevent or cure osteoarthritis. The pain we offer kind of moderate symptomatic relief and it’s really key that we talked to our patient about this. So really managing their expectations. We need to tell them you know exercise needs to be part of their daily routine and its core to their treatment that’s what’s gonna help prevent it from getting worse.
We need to explain to them the limited role that the pain relief can actually play, so they it’s about setting their realistic expectations it may not well become completely pain free and it may be that we’re just trying to enable them to have a tolerable level of pain, so all although I mean obviously ideally will have complete pain resolution, the reality is there will be times where you know they’ve overdone it a little bit with an activity the pain creeps back in and that is normal and to be expected and it’s the body’s way of telling them to slow down a little bit and to relax that joint. So, we just need to be really clear about what can and can’t be achieved with these treatments.
So, thank you very much for listening and I’ve left the reference is there for you to have quick look at keep things for you to think about and the two textbooks at the bottom are really useful sources that you can look at. They’re both available electronically from the library. Obviously, we’ve got NICE guidance and NICE CKS guidance as well, which are obviously key for you to read through, but the website there versus arthritis at the top one and you’ll see it again a bit later down on the list. This is kind of the charity it’s a brilliant resource for patients, but also if you need to kind of brush up quickly on your knowledge of anything off right as related, take a browse around that website if you get time.
