OSTEOARTHRITIS

AKA "Degenerative joint disease," "Osteoarthrosis"

I. Epidemiology

  1. Prevalence increases w/age, most frequently starts in 40's
  2. Slight female predominance

II. Pathogenesis--multifactorial

  1. Thought to result from "normal stresses on abnormal cartilage or abnormal stresses on normal cartilage"
    1. Abnormal stresses include trauma, joint infection, and crystalline arthropathies but apparently not chronic aggressive exercise
  2. Genetic predisposition (perhaps leading to susceptible cartilage makeup) appears to be present

III. Clinical features

  1. Arthralgias worse with joint use, most commonly in PIP, DIP, carpometacarpal, and first MCP joints; also spine, hips, and knees
  2. Less stiffness than in inflammatory arthritides, e.g. rheumatoid arthritis
  3. Minimal signs of inflammation and no known extra-articular features
  4. Radiographic features (usually develop well in advance of sx): joint space narrowing, periarticular bone spur formation, subchondral bonen sclerosis

IV. Treatment

  1. Acetaminophen 4g/d may provide equal pain relief to Ibuprofen 1.2g/d with fewer side f/x for pts with mild-moderate but not severe pain from Osteoarthritis (J. Rheum. 28:1073, 2001--JW; Arth. Rheum. 44:1587, 2001--JW)
  2. NSAIDs
  3. Cox-2 Inhibitors
  4. Symptomatic slow-acting drugs for Osteoarthritis ("SYSADOAs")
    1. Glucosamine sulfate (500mg TID)
      1. In vitro, stimulates cartilage cells to synthesize glycosaminoglycans and proteoglycans
      2. Generally well tolerated; GI discomfort & nausea occur but at similar rates to placebo
      3. Data on effectiveness
  1. In 98 pts with knee DJD, Glucosamine 500mg TID was not ass'd with any improvement in pain scores at 60d c/w placebo (West. J. Med. 172:95, 2000--AFP)
  2. A meta-analysis of 6 randomized trials found sig. effect on symptomatic and functional outcomes in glucosamine c/w placebo (also included analysis of 9 trials of chondroitin sulfate; JAMA 283:1469, 2000--abst)
  3. 212 pts with knee osteoarthritis randomized to glucosamine 1500mg QD vs. placebo; at 3y f/u, sig. diff. in loss of joint space and in symptom scores (favoring glucosamine) (Lancet 357:247, 2001--JW)
  4. In a study in 205 pts with knee OA > 45yo randomized to glucosamine 1.5g/d vs. placebo x 12wks, there were no differences in various pain and function scores (Am. J. Med. 117:643, 2004--AFP)
  5. In a study in 1,583 pts with symptomatic osteoarthritis randomized to glucosamine/chondroitin (1.5g/1.2g daily), either alone, celecoxib 200mg/d, or placebo x 3mos.  Incidence of the main outcome (20% decrease in pain score at 6mos) was not sig. diff. for glucosamine, chondroitin, or both vs. placebo ("Glucosamine/Chondroitin Arthritis Intervention Trial" ("GAIT"); NEJM 354:795, 2006--FP News 3/15/06)
  6. In a study in 318 pts with knee osteoarthritis randomized to glucosamine sulfate 1500mg QD, Acetaminophen 1g TID, vs. placebo, at 6mos, the glucosamine (but not the acetaminophen) recipients had sig. reductions in mean pain/limitation-of-function scores (Arth. Rheum. 56:555, 2007--JW)
  1. Chondroitin sulfate
    1. A component of articular cartilage
    2. In a meta-analysis of 7 randomized trials involving 703 pts w/knee- or hip osteoarthritis. Chondroitin was ass'd with sig. more pain reduction and improvement in function than placebo. No significant adverse effects were noted. (J. Rheum. 27:205, 2000--JW)
    3. A meta-analysis of 9 randomized trials found sig. effect on symptomatic and functional outcomes in glucosamine c/w placebo (also included analysis of 6 trials of glucosamine sulfate; JAMA 283:1469, 2000--abst)
    4. In a study in pts 40-85yo with symptomatic knee osteoarthritis but no severe changes on radiography randomized to chondroitin 4 & 6 sulfate 800mg/d vs. placebo x 2y; after 2y, there was sig. less progression in joint space narrowing in chondroitin group but no sig. diff. in change in pain between the groups (Arth. Rheum. 52:779, 2005--AFP)
    5. In a study in 622 pts with knee osteoarthritis randomized to chondroitin sulfate 800mg/d vs. placebo, over 2y f/u, CS pts had sig. lower pain scores during the first year but not the second year; joint narrowing was sig. lower in CS pts (Arth. Rheum. 60:524, 2009-JW)
    6. In a meta-analysis of 20 randomized trials of chondroitin involving 4,056 pts with knee or hip osteoarthritis, with median treatment duration 25 weeks and median daily dose 1000mg, chondroitin use was associated with a sig. improvement in pain scores, though there was extensive heterogeneity among the trials; analysis of just the three trials that had intention-to-treat data revealed no effect on pain (Ann. Int. Med. 146:580, 2007-JW)
  2. Diacerein
    1. Not available in U.S. as of 2006
    2. In a meta-analysis of 19 randomized trials involving total 2,637 pts with either placebo or NSAID control, diacerein was sig. better than placebo and not sig. diff. from NSAIDs at reducing pain and improving function.  Diacerein was associated with sig. better outcomes 3mos after discontinuation of tx compared with NSAIDs.  Associated with mild-moderate diarrhea (mostly early in treatment course) and darkening of urine. (Arch. Int. Med. 166:1899, 2006--FP News)
  1. Topical lidocaine
    1. Lidocaine 5% patch vs. celecoxib 200mg/dwas associated with similar degrees of pain relief at 6wks in a randomized trial in 143 pts with osteoarthritis (in a poster presented at the American Pain Society meeting by BS Galer et al., reported in Family Practice News, 8/15/2005)
  2. Hyaluronan, intra-articular
    1. Derivative of hyaluronic acid; available commercially in 2 forms: sodium hyaluronate (Hyalgan) and hylan G-F 20 (Synvisc)
    2. Replaces natural hyaluronan which seems to have a protective effect on joints
    3. Shown to reduce knee osteoarthritis sx in short-term studies; very expensive as of 1998
    4. A randomized trial in 120 pts with knee OA showed no symptomatic improvement with intra-articular hyaluronan vs. placebo injections (Arch. Int. Med. 162:292, 2002--JW)
    5. In a study of 100 pts with knee osteoarthritis with sx refractory to other non-surgical interventions, e.g. NSAIDs, randomized to intra-articular Hylan G-F 20 Qwk x 3 vs. intra-articular betamethasone x 1, there were no sig. diffs. at 6mos in knee function scores or pain scores (J. Bone Joint Surg. Am. 85:1197, 2003--JW)
    6. In a meta-analysis of 22 RCTs of intra-articular hyaluronic acid for knee osteoarthritis, it was ass'd with only mild improvements in sx (JAMA 290:3115, 2003--JW)
  3. Ginger extract--261 pts with knee osteoarthritis randomized to ginger extract vs. placebo x 6wks; ginger pts had sig. greater likelihood of improvement of pain (63% vs. 50%) but also sig. more likely to have GI side f/x (45% vs. 16%) (Arth. Rheum. 44:2531, 2001--JW)
  4. Steroid Joint Injection
    1. In a meta-analysis of 10 randomized trials of corticosteroid injections for knee osteoarthritis, such tx was found to be associated with statistically significant symptom improvement for at least 16 weeks after treatment (BMJ 328:869, 2004--JW)
  5. Acupuncture
    1. In a study of 570 pts with knee OA randomized to acupuncture, sham acupuncture, or education, over 26wks, acupuncture recipients had sig. greater improvements in pain and physical function scores than the pts in the other 2 groups (Ann. Int. Med. 141:901, 2004--JW)
    2. In a study of 97 pts with knee OA randomized to acupuncture vs. sham acupuncture x 12wks, acupuncture recipients had sig. greater improvements in pain and physical function scores (BMJ 329:1216, 2004--JW)
    3. In a study in 294 pts with chronic knee osteoarthritis randomized to traditional Chinese acupuncture, sham acupuncture (both in 12 sessions over 8 weeks), or assignment to a waiting list, at 8wks the traditional acupuncture recipients had sig. less pain and stiffness than those who received sham acupuncture or the waiting list but at 26 and 52 weeks there were no sig. differences. (Lancet 366:136, 2005--JW)
    4. In a study in 1,039 pts with chronic (> 6mos) knee pain due to osteoarthritis randomized to Chinese acupuncture, sham acupuncture, or standard physician consultations (all received physical therapy and NSAIDs), at 26wks, sig. improvement in pain and function scores were sig. more likely in both acupuncture and sham-acupuncture groups c/w standard-treatment group (53%, 51%, and 29% respectively) (Ann. Int. Med. 145:12, 2006--JW)
  6. Arthroscopic lavage & debridement--Not more effective than a sham procedure in a 2y randomized trial in 180 pts with knee osteoarthritis (NEJM 347:81, 2002--JW)
  7. Physical therapy--Ass'd with increased walking tolerance and decreased sx c/w placebo in a controlled trial of 83 pts with knee osteoarthritis (Ann. Int. Med. 132: 173, 2000--AFP)
  8. Therapeutic knee taping--87 pts with knee osteoarthritis randomized to therapeutic knee taping (designed to provide medial glide, medial tilt, and AP tilt to the patella and unload the infrapatellar fat pad and pes anserinus), control taping, or no taping.  At 3wks, therapeutic taping group had sig. greater reductions in pain & disability than the other two groups (BMJ 327:135, 2003--AFP)
  9. Joint replacement surgery as a last resort