OSTEOARTHRITIS: AN EMERGING

MEDICAL CHALLENGE
DR O O ADELOWO M.B.B.S (Ib), FMCP (Int Med),
FWACP, FRCP (Edin) FRCP(Lond)

Professor of Medicine and Consultant
Rheumatologist, Lagos State University Teaching
Hospital, Ikeja

femiadelowo2003@yahoo.com

Osteoarthritis:Incidence/Prevalence
Commonest articular disease worldwide
Affects 20 million in USA
1.5 million in U.K
9 million all arthritis UK
2nd to IHD as cause work disability in men >50yrs
Constitutes about 80% of our rheumatology practice
Radiologic changes osteophytes in 50% aged 65+
Higher incidence in Afro American female and Japanese
Low incidence South African blacks, east Indians, Southern
Chinese
Burdens of Osteoarthritis
Anxiety
Depression
Helplessness
Limitations of daily activities
Job Limitation
Economic Direct and Indirect costs appliances, lost wages,
travel costs
Mortality and Morbidity
Slow disease progression over years
Pain initial and principal source
Joint stiffness, instability, deformity
Predisposition to falls and fracture
Weight gain and consequences
Demographics
Prevalence rises with age
Mostly females
DIP and PIP with Heberden and Bouchard in females
Middle aged to elderly : 45-65
Uncommon less than 30

JOINTS AND SYMPTOMS
Knee, Hips, Ankle, Hands, Spine apophyseal
Knee most likely to cause symptoms than others(Ref)
Joint Pains initially activitiy, relief by rest
Later pains at rest and night
Joint morning stiffness
Swelling
Crepitus
Warmth to touch

Lawrence RC et.al. Arthritis Rheum.1998;41:778-99
AMERICAN COLLEGE OF
RHEUMATOLOGY(ACR) CRITERIA
HIP- Hip pain for most days of prior month
ESR< 20mm/hr
Radiograph femoral and/or acetabular osteophytes
Radiograph hip joint space narroing
KNEE- Knee pain for most days prior month
Crepitus on active joint motion
Morning stiffness < 30mins
Age > 38
Bony enlargement of knee on examination
ACR CRITERIA contd.
HAND- Hand pain,aching or stiffness most days of prior month
Hand tissue enlargement of 2 or more selected hand
joints
MCP swelling in < 2 joints
Hand tissue enlargement of > 2 DIP
Deformity of > 1 of selected hand joints


Altman R et.al. Arthritis Rheum. 1986;29:1039-49
Altman R.et.al, Arthritis Rheum 1990;34:505-14
Physical Examination
Swelling effusion, osteophytes, bony enlargement
Tenderness joint line
Crepitus
Limitation
Deformity Genu Valgum, Genu Varus
Heberden, Bouchards nodes
Poor correlation of pain and radiographic changes. (Ref)

Bedson J and Croft PR. BMC Musculoskeletal Disord. 2008;9(1):116
Sources of Pain
Joint effusion capsular stretch
Subchondral bone vascular distension vasa nervorum
Periarticular Bursitis
Periarticular muscle spasm
Damaged meniscus
Tendon Stretch
DIFFERENTIAL DIAGNOSES

RHEUMATOID ARTHRITIS
GOUTY ARTHRITIS
PSEUDO GOUT
EROSIVE ARTHRITIS
PSORIATIC ARTHRITIS
TRAUMATIC SYNOVITIS
FIBROMYALGIA SYNDROME
Aetiology
PRIMARY- IDIOPATHIC
SECONDARY
1 Metabolic- Ochronosis; Acromegaly; Haemochromatosis,Calcium
crystal deposition, Diabetes
2 Anatomic-
Slipped femoral epiphysis
Epiphyseal dysplasia
Legge-Perthe disease
Congenital dislocation of the hip
Leg length inequality
Hypermobility syndromes-Benign,Hereditary



AETIOLOGY contd
3. Traumatic
Joint trauma
Fracture through a joint
Joint surgery-meniscectomy
Chronic injury(occupational/sports)
4. Inflammatory
Any inflammatory arthritis
Gouty arthritis
Septic arthritis
Pathophysiology
Stage 1
Proteolytic breakdown cartilage matrix
Chondrocyte metabolism disorder
Increased production of enzymes collagenase, elastates,
stromelysin
Destruction of cartilage matrix
Pathophysiology Contd
Stage 2
Cartilage Fibrillation
Imbibing of Water
Release proteoglycan and collagen fragments
Pathophysiology Contd
Stage 3
Cartilage breakdown products induce inflammation of synovium
Synovial macrophage produce cytokines IL -1 and TNF-alpha
Cytokines cause further destruction
Stimulate chondrocytes to produce metalloproteinases and NO
Investigations

X-rays
Osteophytes diagnostic
Joint space narrowing
Subchondral sclerosis
Subchondral cysts
Disparity with symptoms
M.R.I
Bone Densitometry
Thermography
Bone Scan
Arthroscopy
Management
Optimal management
Non-Pharmacologic and Pharmacologic
Team Approach Rheumatologist, Physiotherapist,
Occupational therapist, nutritionist, orthopaedic surgeon
Medical treatment- Rheumatologist
Surgical treatment- Orthopaedic Surgeon




. Jordan KM et. al. Ann.Rheum Dis 2000;59:936-44
NON PHARMACOLOGIC
Lose Weight
Assistive Devices walking sticks, walking frame
Hydrotherapy
Physical exercises walking, bicycling
Aerobic excercises quadriceps strengthening
TENS
Infrared-popular but not effective
Therapeutic taping
Significant reduction in pain
Adjunct to drugs and exercises

Hinman RS et al. Rheumatology 2003: 42:865-869

PHARMACOLOGIC
Paracetamol (PCM)
First line treatment by EULAR, ACR, BSR
Dose at 4gm daily
PCM as effective as NSAIDs(1)
No statically significant symptomatic effect vs placebo[2]
NSAIDs more effective.[3,4]

!. Brandt IC B et al. Rheumatology 2006 - 45(11):1389-1392 (!)
2. Miceli-Richard et al. Ann. Rheum Dis. 2004 - 63:923-930
3. Boureau F et al. Ann. Rheum. Dis. 2004 63:1028-1034
4. Zhang W et al. Ann. Rheum. Dis. 2004 63:901-907

Pharmacologic Contd
NSAIDs
Most widely used
No NSAID superior to another in efficacy
NSAIDs side effect varies ARAMIS study
Start from lowest dose
Use only in acute pain exacerbation
Use with food
Short acting NSAIDs for acute exacerbation
Never combine NSAIDs
Avoid alcohol/smoking

Pharmacologic Contd
NSAIDs contd.
Minor side effects Dyspepsia, flatulence, nausea
Use H
2
receptor blocker for minor side effects
Serious GIT effects Perforation, ulceration, bleeding
Predisposing factors Age, steroids, comorbididty, previous PUD,
alcohol, smoking
Prophylaxis Misoprostol, PPI
Pharmacologic Contd
NSAIDs contd
Selective COX-2 inhibitors
Rofecoxib, Celecoxib, Valdecoxib, Eterocoxib
CVS and cerebrovascular morbidity and mortality
No difference from NSAIDs in efficacy
Less GIT side effects
Use Celecoxib less than 400mg
Other COX-2 withdrawn
Nimesulide COX-2 preferred: withdrawn for hepatotoxicity.
Amitryptiline for night pain
Pharmacologic Contd
Narcotic Analgesis
Tramadol, Dextropropoxyphene, Codeine
Alone or in combination with NSAID
Tramadol/Paracetamol(375/325) effective(1,2)
Constipation may be troublesome
Transdermal Opiods- Buprenorphine

1.Silverfield TC et. al.. Clin, Ther. 2002 . 24[2]:282-297
2.Rosenthal N et al. J. Am. Geriatr. Soc. 2002: 50(Suppl): S145
Intra Articular steroids
Effective
Not more than 4 injections per year
Concern with cartilage damage
No difference in efficacy methylprednisolone vs.
Triamcinolone
Metaanalysis of studies. 1980 2002
Short term improvement in symptoms
Significant improvements up to 9 monhs

Bruce Arroll and Felicity Goodyear Smith BMJ. 2004 328(7444). 869
Intra Articular Hyaluronan(HA)
Effective minimal side effects
Higher molecular weight HA more effective than LMW
Metaanalysis of 20 RCT HA vs placebo
Delayed onset of efficacy, longer lasting
Not beneficial in radiographic loss of joint space
DMOAD- protects superficial cartilage from erosion

Gossec L and Dougados M. Ann. Rheum. Dis. 2004. 63:478-482
Chen T Wang et. al. Journal of Bone and Joint Surgery (American) 2004
86:538-545
Topical Applications
Capsaicin cream as adjunct
Depletes substance P in joint pain fibres
Acetylsalicylic ointment
Glucosamine cream work in progress
Topical Diclofenac efficacious and safe

Sanford H. Roth and J. Zev Shainhouse. Arch. Int. Med. 2004: 164:
2017-2023
Anti Osteoporotic
Novel approach
Biphosphonates may be useful
Risedronate vs. placebo retention of vertical trabecular structure,
subchondral bone (Ref)

Buckland-Wright JC et. al. Rheumatology. 2007; 46[2]:257-264
Food Supplements Glucosamine
Sulphate, Chondroitin Sulphate
Controversies on efficacy
Metaanalysis
Medline, Embase, Cochrane
Significant efficacy joint space narrowing and WOMAC
Chondroitin effective
Sparse data on structural effect[1]
Study 202 patients [GS]
Dose 1500mg daily vs placebo
3-year effect-retarded progression
Possible disease modification DMOAD[2]

Richy F et.al. Arch. Int. Med. 2003;163:113
Pavelka K et.al. Arch Int Med 2002;162:2113-2123
Food Supplements Glusomamine
Sulphate, Chondroitin Sulphate Contd
Meta analysis
GS positive effect symptomatic and structural outcomes
Results not extrapolated on OTC preparations
GAIT(American) (1) study vs GUIDE(European) (2)
GAIT- RCT GHCHLvs CS vs GHCL+CSvs CE Dose 500mg tid
GUIDE- CGSvsPCM 1,500mg O.D
CGS reduces symptoms and rate to knee repl. 73% in 5years
1.Daniel O. et.al The New Engl.j.Med 2006;354:795-808
2.Herrero-Beaumont G et. al Arthritis Rheum.9Suppl 2005(ACR abstract)
Reginster J. Y. et al. Rheumatology 2007 46[5]: 731-735
MODE OF ACTION: GLUCOSAMINE
ANABOLIC EFFECTS
INCREASES PROTEOGLYCAN SYNTHESIS
INCREASES PERLECAN AND AGGRECAN mRNA
INCREASES PROTEIN KINASE PRODUCTION
INCREASES ADHESION OF CHONDROCYTES TO
FIBRONECTIN

ANTICATABOLIC
DECREASES STROMELYSIN
DECREASES AGGRECANASE
DECREASES COLLAGENASE ACTIVITY
GLUCOSAMINE Contd.
ANTIINFLAMMATORY
INHIBITION SUPEROXIDE RADICALS
INHIBITION LYSOSOMAL ENZYMES
INHIBITION NITRIC OXIDE SYNTHESIS
DECREASES INTERLEUKIN-1 BETA



Pipemo M et.al. Osteoarthritis Cartilage.2000;8:207-212
Pipemo M. et. al. Osteoarthritis Cartilage 1998;6:393-399
Setnikar I et.al. Arzneimittelforschung.1991;41:542-545
Shikhman AR et.al .Arthritis Rheum 1999;42(Suppl):S381
Acupuncture
Control Trial
24 acupuncture vs. sham 570 patients
Greater improvement function but not in pain by 8 weeks
Improvement after 26 weeks
Many participants drop out

Berman BM et al. Ann. Intern. Med 2004. 141(12):901-910

OTHER MANAGEMENT
CLOSED INTRA ARTICULAR LAVAGE
ARTHROSCOPIC LAVAGE/ SURGERY
GARLIC,GINGER AND ALL SORTS- NO
CONTROLLED PLACEBO TRIAL EVIDENCE!!
TAKE HOME MESSAGES
ARTHRITIS NOT ONE DISEASE
MORE THAN 200 TYPES/CAUSES
OSTEOARTHRITIS VERY COMMON.
OA KNEE PARTICULARLY COMMON IN WOMEN
COLLABORATION BETWEEN RHEUMATOLOGIST, ORTHOPAEDIC
SURGEON AND PARA MEDICAL PERSONNEL
PARACETAMOL BEFORE NSAIDS
NO NSAID SUPERIOR TO ANOTHER. RESPONSES/ SIDE
EFFECTS VARY
NARCOTIC ANALGESICS USEFUL SINGLY OR COMBINATION

TAKE HOME MESSAGES contd.
INTRA-ARTICULAR STEROIDS USEFUL
INTRA ARTICULAR HYALURONATE MAY BE A DMOAD
GLUCOSAMINE SULPHATE AND CHONDOITIN SULPHATE
MAY BE DMOAD.AT DOSE 1500mg
NOT SYMPTOM MODIFICATION
ONLY USEFUL FOR OA. NOT BACK PAIN,SOFT TISSUE
RHEUMATISM OR ANY OTHER ARTHRITIS.
REFER EARLY TO RHEUMATOLOGIST



THANK YOU!