Osteoarthritis Flashcards
OA: Mx NICE Guidelines
NICE published guidelines on the management of osteoarthritis (OA) in 2014
- all patients should be offered help with weight loss, given advice about local muscle strengthening exercises and general aerobic fitness
- paracetamol and topical NSAIDs are first-line analgesics. Topical NSAIDs are indicated only for OA of the knee or hand
- second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids. A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2 inhibitors. These drugs should be avoided if the patient takes aspirin
- non-pharmacological treatment options include supports and braces, TENS and shock absorbing insoles or shoes
- if conservative methods fail then refer for consideration of joint replacement
OA - Role of Glucosamine
What is the role of glucosamine?
- normal constituent of glycosaminoglycans in cartilage and synovial fluid
- a systematic review of several double blind RCTs of glucosamine in knee osteoarthritis reported significant short-term symptomatic benefits including significantly reduced joint space narrowing and improved pain scores
- more recent studies have however been mixed
- the 2008 NICE guidelines suggest it is not recommended
- a 2008 Drug and Therapeutics Bulletin review advised that whilst glucosamine provides modest pain relief in knee osteoarthritis it should not be prescribed on the NHS due to limited evidence of cost-effectiveness
OA - Mx Example Question
A 74 year old female was admitted to the medical ward initially for treatment of a CURB = 4 community acquired pneumonia. She is now awaiting discharge but since her illness, she has not returned to her pre-morbid state. Her past medical history include two previous myocardial infarctions, hypertension, type 2 diabetes mellitus, duodenal ulcer and obesity. In addition, the physiotherapists report significant right knee pain to be contributing to poor mobility. On questioning, the patient reports that the pain is chronic and has been progressively worsening for about 3 years.
Her GP had sent her for two X rays previously that demonstrated cartilage loss and osteophyte formation, with reduction in joint space. On examination, you note significant crepitus in the right knee, with reduced range of movements in flexion and extension. You also note boney outgrowths in the proximal interphalangeal joints of her second and third digits of her right hand. She had successfully lost 9kg in weight and had previously taken 1g paracetamol four times a day regularly but neither measure seemed to help her pain.
What is the most appropriate next step?
Increase 500mg paracetamol as required Oral ibuprofen > Topical diclofenac Oramorph as required Glucosamine
The patient describes osteoarthritic symptoms that have persisted despite non-pharmacological therapies (weight loss) and paracetamol on a regular basis. Her past medical history of duodenal ulcer should make you wary of oral NSAIDs while her previous MIs indicate selective COX-2 inhibitors should be used with caution. Opiods are not the second line therapies for osteoarthritis. The evidence for glucosamine is limited and is not recommended for use under the NHS. Topical NSAIDs such as diclofenac or topical capsaicin as an adjunct are reasonable options in this setting. A 3rd line possibility if topical NSAIDs are not efficacious and in this case, where oral NSAIDs are contraindicated, are intraarticular steroid injections, which have been demonstrated to produce significant symptomatic improvements in the knee joint when compared against placebo (although evidence is weaker for other joints). Interestingly, an inflammatory element is not required for symptomatic benefits.
OA X-ray Changes
X-ray changes of osteoarthritis
- decrease of joint space
- subchondral sclerosis
- subchondral cysts
- osteophytes forming at joint margins
OA - 2nd line Mx: Example Question
62-year-old woman complains of knee pain. She has struggled with pain for several years. She finds that it gets worse through the day and is relieved by resting. She does not normally come and see doctors but the pain has gotten to the point where she would like additional treatment. She is not keen on surgery as of yet. She is known to have osteoarthritis. She has been taking paracetamol but not tried any other medication. What is the most appropriate strategy to further help relieve her pain?
Codeine Oral NSAIDs > Topical NSAIDs Intra-articular steroid injection Oral morphine
The correct answer is topical NSAIDs. This is a case of managing pain in osteoarthritis. As she has knee osteoarthritis the first line of treatment can include paracetamol and topical NSAIDs. Topical NSAIDs are only appropriate for osteoarthritis of the hands and knees. Second line treatment includes oral NSAIDs, codeine, capsaicin cream and intra-articular corticosteroids.
Secondary Causes of OA - Example Question
A 40 year old man presents with arthralgia in his ankles. He reports he has had it for years, but it has worsened in the last few months. He denies any previous trauma to his ankles. On examination he has tenderness and reduced range of movement in his ankles. He takes Ibuprofen 400mg TDS, and Paracetamol 1g QDS. X-rays of his ankles show joint space narrowing and some subchondral sclerosis. Previous blood tests show he is negative for rheumatoid factor and anti-CCP antibody. What is the best next investigation?
CT ankle Repeat x-ray in 3 months Calcium and phosphate levels > Ferritin and total iron binding protein PET scan
This gentleman clearly has osteoarthritis given the clinical and radiological findings. Ankle joints are not typical for primary osteoarthritis. The most common cause of secondary osteoarthritis is trauma which does not seem applicable given the history so other causes need to be considered such as haemochromatosis. Therefore checking the ferritin and total iron binding protein would be appropriate as a screen for this.
The further imaging listed would not aid a further diagnosis at this stage. MRI or USS could be considered to look for synovitis or enthesitis if concerned about a seronegative arthritis leading to secondary osteoarthritis but these are not listed as options.
Most common site of Hand OA?
= Trapeziometacarpal joint
= Base of thumb pain and swelling!
OA Mx again
OA Initial Mx
Non-pharmacological therapies (weight loss) and paracetamol on a regular basis.
PUD = be wary of oral NSAIDs
Prev MIs indicate selective COX-2 inhibitors should be used with caution.
The evidence for glucosamine is limited and is not recommended for use under the NHS.
Topical NSAIDs such as diclofenac or topical capsaicin as an adjunct for hand and knee OA
A 3rd line possibility if topical NSAIDs are not efficacious OR where oral NSAIDs are contraindicated, are intraarticular steroid injections, which have been demonstrated to produce significant symptomatic improvements in the knee joint when compared against placebo (although evidence is weaker for other joints). Interestingly, an inflammatory element is not required for symptomatic benefits.
