Osteoarthritis Diagnosis and management
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An overview of diagnosis and management of Osteoarthritis
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Osteoarthritis Diagnosis and management
- 1. Rachmat Gunadi Wachjudi Lahir di Garut, 16-1-1955Lahir di Garut, 16-1-1955 PendidikanPendidikan SD-SMA : GarutSD-SMA : Garut Dokter umum: FK UNSRI PalembangDokter umum: FK UNSRI Palembang Internist: FK UNPAD BandungInternist: FK UNPAD Bandung RReumatologi :eumatologi : FK UI Jakarta & Arthritis FoundationFK UI Jakarta & Arthritis Foundation of WAof WA Pekerjaan:Pekerjaan: Ka DivKa Div Reumatologi RS Dr Hasan SadikinReumatologi RS Dr Hasan Sadikin Organisasi ProfesiOrganisasi Profesi IDI,IDI, IRA, PAPDI, PEROSI, PERALMUNIIRA, PAPDI, PEROSI, PERALMUNI, APLAR,, APLAR, IPSIPS
- 3. The Coming Epidemic of ARTHRITIS. 160[24]. 9-12-2002. Time Magazine. Arthritis: the most common is Osteoarthritis
- 4. Prevalence of Specific Types of Arthritis • The most common form of arthritis is osteoarthritis. Other common rheumatic conditions include gout, fibromyalgia and rheumatoid arthritis. • An estimated 27 million adults had osteoarthritis in 2005. – Arthritis Rheum 2008;58(1):26–35. • An estimated 1.3 million adults were affected by rheumatoid arthritis in 2005. – Arthritis Rheum 2008;85(1):15–25. [Data Source: 1985 Mayo Clinic] [Data Source: 2000 Census Data] • An estimated 3.0 million adults had gout in 2005, and 6.1 million adults have ever had gout. – Arthritis Rheum 2008;58(1):26–35. [Data Source: 1996 NHIS] • An estimated 5.0 million adults had fibromyalgia in 2005. – Arthritis Rheum 2008;58(1):26–35.
- 6. Rheumatic ailments 1% 1% 6% 4% 4% 69% 3%2% 10% Osteoarthritis SLE Rheumatoid Artritis Gouty Artritis Sp Arthritis Systemic Sclerosis Osteoporosis Soft Tissue Rheumatism others
- 8. slide 8 Vicious Cycles in Osteoarthritis (OA) Imbalance of... Cytokines Prostaglandin E2 Cartilage matrix fragments Free radicals Proteolytic enzymes Protease inhibitors Proteolytic destruction of cartilage matrix Altered mechanical loading of cartilage and ligaments Remodeling of Bone osteophytosis, subchondrial sclerosis Phasic synovial Inflammation & angiogenesis Peripheral & central sensitization pain Impaired mobility: Reduced exercise, muscle weakness, joint laxity Aetiology/Riskfactors Disease/Outcome
- 10. Felson DT, Osteoarthritis of the knee, N Engl J Med 2006;354:841-8 Osteoarthritic jointOsteoarthritic joint •Softening and swellingSoftening and swelling •FibrillationFibrillation •Full thickness cracksFull thickness cracks •EburnationEburnation •Subchondral cystsSubchondral cysts •Subchondral sclerosisSubchondral sclerosis •Osteophyte formationOsteophyte formation
- 11. Clinical characteristics • Deep aching pain, poorly localized • May occur in one or two joints or be generalized • Pain occurs in involved joint and is relieved by rest • Joint stiffness in morning and after periods of inactivity • Aching “night pain” is common (Loesser et al, 2001)
- 13. Diagnosis • History: age, functionality, degree of pain, stiffness, time of occurrence (e.g., morning, at rest, during activity) • Physical examination: range of motion, tenderness, bony enlargement of joint • Laboratory findings: radiograph, CBC, synovial fluid analysis (Loesser et al, 2001; Manek et al, 2000)
- 14. Risk factors for knee osteoarthritis - female sex - aging - overweight - joint injury - misalignment - joint laxity - family history - Heberden's nodes - occupational and recreational use Dr. Zhang, EULAR 2009: : Abstract OP-0209. Presented June 12, 2009
- 15. Clinical diagnosis 3 clinical symptoms: - pain on use - short-lived morning stiffness - functional limitation 3 signs: - crepitus - restricted movement - bony enlargement Dr. Zhang, EULAR 2009: : Abstract OP-0209. Presented June 12, 2009 This clinical diagnosis: correctly identify 99% of patients with knee osteoarthritis.
- 16. Hand OA Heberden’s nodes (DIP) Bouchard’s nodes (PIP)
- 17. 04/08/1504/08/15 RGW IRA BandungRGW IRA Bandung 1717 Goals of Arthritis managementGoals of Arthritis management • Relieve pain/inflammationRelieve pain/inflammation • Minimize risks of therapyMinimize risks of therapy • Retard disease progressionRetard disease progression • Provide patient educationProvide patient education • Prevent work disabilityPrevent work disability • Enhance quality of life and functionalEnhance quality of life and functional independenceindependence
- 18. Treatment Principles • Non-Pharmacologic – Education – Physiotherapy • Exercise program • Pain relief modalities – Aids and appliances • Pharmacologic – Medical Treatment • Surgical Treatment • Complementary and Alternative Medicine
- 19. Nonpharmacologic Management of Pain • Temperature • Electrical nerve stimulation, acupuncture • Relaxation techniques, biofeedback, hypnosis • Physical therapy • Occupational therapy • Nerve block and tumor site radiation Gloth FM III. Clin Geriatr Med. 2001;17:553-73.
- 20. Pharmacologic therapy • Analgesic and anti-inflammatory • Intra-articular corticosteroids • Intra-articular hyaluronic acid • Disease modifying Osteoarthritis Drugs
- 21. Treatment Considerations First, perform aFirst, perform a comprehensive assessment of pain and functioncomprehensive assessment of pain and function Mild-to-moderate pain Acetaminophen Moderate-to-severe pain COX-2 NSAIDS Severe arthritis pain: COX-2 drugs and non-specific NSAIDs do not provide substantial relief Opioids Drug therapy ineffective and function severely impaired Surgical Treatment (ACR, 2000; APS, 2002; Manek et al, 2000)
- 22. Disease modifying Osteoarthritis Drugs • Nutraceuticals • Diacerein • SOD ? • Hyaluronan ? • Doxy/Minocyclin
- 23. Nutraceuticals • Glucosamine • Chondroitin • Glucosamine + Chondroitin ?
- 24. Diacerein • anti interleukin 1 • studi 507 penderita selama 3 tahun diacerein 2x50 mg memperlambat progresifitas gambaran radiografi OA panggul secara bermakna. • Terdapat efek perbaikan nyeri
- 25. Doxycycline • Studi 431 wanita obese dengan OA, • Th/ doxycycline 2x100mg >< placebo selama 3 bulan perlambatan progresifitas penyempitan celah sendi pada doxycycline. • Tidak ada perbedaan bermakna dalam mengurangi keluhan nyeri lutut. (Brandt et al., 2005)
- 26. Calcitonin & Estrogen • memiliki efek proteksi terhadap erosi permukaan kartilago sendi secara bermakna. • DMOAD di masa mendatang ?
- 28. Complementary and Alternative Medicine • Popular and widely used among patients with rheumatic and musculoskeletal disease • Marketing and word of mouth, ready availability, and interest in ”natural” treatments contribute to their popularity. • Scientific basic and clinical trials of most therapies is limited or lacking
- 29. • Herbs, Supplements, and Vitamins – Herbal remedies are the fastest growing form of CAM therapy in US – Viewed as “natural” and therefore safe, herbs actually are potent medications – Warning!!!: Most herbs used to relive pain affect eicosanoid metabolism, the side effects may be similar to those of NSAIDs.
- 30. Rose hips
- 31. slide 31 Known Modes of Action – Inhibition of leukocyte migration – Inhibition of leukocyte oxidative burst – Reduction of C-reactive protein CRP (anti-inflammatory) – Galactolipids like GOPO™ and similar substances were identified as bioactive constituents of i-flex – i-flex and its constituents markedly modulate expression of genes that are responsible for cartilage erosion and rebuilding
- 32. slide 32 * 3 weeks of rosehip treatment resulted in a significant reduction in pain when compared to placebo (p<0.014) DeltaDecrease:DeltaIncrease 2.1 ± 16.8 * -8 -6 -4 -2 0 2 4 6 8 7.4 ± 14.9 * Rose hip Placebo Winther et al. Scand J Rheumatol 34:302-308 (2005) Change in WOMAC pain after 3 weeks treatment in the group starting on i-flex™ and the group starting on placebo
- 33. slide 33 Change in the consumption of acetaminophen tablets (500 mg) during 3 months i-flex™ treatment * A decline of one acetaminophen tablet per day per patient was seen in the rosehip group (p<0.031) DeltaDelta Decrease:Increase Rosehip 14.0 ± 24.0 7.9 ± 15.5 -14 -12 -10 -8 -6 -4 -2 0 2 4 6 8 Placebo * Winther et al. Scand J Rheumatol 34:302-308 (2005)
- 34. slide 34 The percentage of patients who reported a reduction in pain on a yes/no basis after three months treatment *Approx. 1 in 3 responded with a reduction in pain in the placebo group, whereas a much higher number reported a reduction while on rosehip (p<0.01) 100 88% 36% 0 10 20 30 40 50 60 70 80 90 %Responders Rosehip * Placebo Sub-study analysis of Rein et al. Phytomedicine 11(5): 383-391 (2004)
- 35. Optimizing Treatment Medical Concerns • Consideration of comorbidities and concomitant therapies • Evaluation of risk factors for every predictable complications • Clinical Review ACR Subcommittee on OA Guidelines. Arthritis Rheum. 2000;43:1905-15.
- 36. Terimakasih
Notes de l'éditeur
- Loeser JDF, Butler, SH, Chapman CR et al. Bonica’s Management of Pain. 3rd ed. Baltimore: Lippincott Williams Wilkins; 2001:506-507.
- The typical patient with osteoarthritis (OA) is middle-aged or elderly and complains of pain in the knee, hip, hand or spine. The patient usually has pain and stiffness in and around the affected joint and some limited function. Pain typically worsens with use of the affected joint and is alleviated with rest. Pain at rest or nocturnal pain is a feature of severe OA. Morning stiffness lasting less than 30 minutes is common. Patients with OA of the hip may complain of problems with gait. Pain can vary greatly in site and nature, sometimes making early diagnosis difficult. The pain may be felt in the area of the buttock, groin, thigh or knee and can vary in character from a dull ache to a sharp, stabbing pain. Hip stiffness is common, particularly after inactivity. Early physical signs of OA of the hip include restriction of internal rotation and abduction of the affected hip, with pain occurring at the end of the range of motion. Patients with OA of the knee often complain of instability or buckling, especially when descending stairs or stepping off curbs. Patients with OA of the hands may have problems with manual dexterity. The physical exam should include a careful assessment of the affected joints, surrounding soft tissue and bursal areas. Crepitus, which is felt on passive range of motion, is a frequent sign of OA of the knee. Periarticular disorders, such as anserine, infrapatellar or prepatellar bursitis, should be ruled out. These disorders can be mistaken for OA. Patients with erosive OA may have signs of inflammation in the interphalangeal joints of the hands. This inflammation can be mistaken for rheumatoid arthritis, which causes similar joint swelling. However, OA generally does not have an inflammatory component, except in advanced disease. Radiographs usually confirm the diagnosis of OA, although the findings are nonspecific. The key radiographic features of the disease are a loss of joint space and the presence of new bone formation. Most routine blood tests are normal in patients with uncomplicated OA. Analysis of synovial fluid usually reveals a white blood cell count of less than 2,000 per mm3 (2.03 109 per L). Loeser JDF, Butler SH, Chapman CR et al. Bonica’s Management of Pain. 3rd ed. Baltimore: Lippincott Williams Wilkins; 2001:509. Manek J, Lane NE. Osteoarthritis: current concepts in diagnosis and management. Am Fam Physician. 2000;61:1795-804.
- The nonpharmacologic treatment of pain is an adjunct to pharmacologic therapy. Examples of nonpharmacologic modalities include1 • Temperature: cold to suppress the release of products from tissue damage; warmth to stimulate production of endogenous opioids • Stimulation of endogenous opioid release: transcutaneous electrical nerve stimulation (TENS) percutaneous electrical nerve stimulation (PENS) acupuncture Relaxation techniques, biofeedback, and hypnosis are helpful because they involve the role of mental focus and anxiety in pain management. Physical and occupational therapy may include the use of braces or splints, changes in biomechanics, and exercise itself, all of which have been demonstrated to improve pain. Gloth FM III. Principles of perioperative pain management in older adults. Clin Geriatr Med. 2001;17:553-573.
- Treatment of osteoarthritis should be individualized. Comorbid conditions such as cardiac disease, hypertension, peptic ulcer disease or renal disease must be considered, as should the patient&apos;s needs and expectations. A wide range of treatment options are available for managing osteoarthritis pain. The American Pain Society published their guidelines for the treatment of arthritis in March 2002: those guidelines are summarized on this slide. In 2000, The American College of Rheumatology also published criteria for the treatment of osteoarthritis of the hip, knee and hand. Generally, the ACT treatment options are as follows: Nonpharmacologic Management · Patient education · Exercise · Assistive devices · Weight management Pharmacologic Management · Acetaminophen · NSAIDS; COX-2 inhibitors · Glucosamine · Topical/local analgesics · Intra-articular corticosteroid injections · Surgery · Opioids American College of Rheumatology. Recommendations for the Medical Management of Osteoarthrits of the Hip and Knee. Arthritis and Rheumatism. 2000;43:1905-1915. Arthritis Pain Guideline Panel. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis and Juvenile Chronic Arthritis. Glenview, IL: American Pain Society; 2002. Manek J, Lane NE. Osteoarthritis: current concepts in diagnosis and management. Am Fam Physician. 2000;61:1795-804.
- If nonpharmacologic measures and the use of acetaminophen* fail to provide adequate symptom relief, patients should be assessed for their risk of developing upper gastrointestinal (UGI) complications and adverse renal effects prior to the selection and initiation of oral anti-inflammatory therapy. 1 Risk factors for UGI complications include the following1: • Age 65 years • Comorbid medical conditions • Oral glucocorticoids • History of peptic ulcer disease • History of UGI bleeding • Anticoagulants • Smoking? • Alcohol consumption? Risk factors for reversible renal failure in patients with intrinsic renal disease include the following1: • Age 65 years • Hypertension • Congestive heart failure • Concomitant use of diuretics • Concomitant use of angiotensin-converting enzyme inhibitors *Paracetamol in some countries. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum. 2000;43:1905-1915.