HDT Unit 2: Nutraceuticals Global Market Overview And Growth Of Nutraceutical...
Osteoarthritis Diagnosis and Treatment
1. Knee joint OA
Diagnosis and Management
Rheumatology Division
Dr Hasan Sadikin Hospital Bandung
2. Case Presentation
Aceng is a 48 yo male primary school teacher who
presents to the Rheumatology Clinic c/o 8-10 yrs of
B knee pain. His active lifestyle is severely
compromised by his knee pain.
6. Osteoarthritis
• Epidemic in the US
– More people over 65 than teenagers
• One baby boomer will turn 55 every
seven seconds for the next 20 years
– Increased life span
• 1940: 61.4 yrs/men, 65.7 yrs/women
• 2008: 75.4 yrs/men, 80.0 yrs/women
• 66 million (1/3) US adults will have OA
by 2030
• Estimated that only 10% of population
currently seeks treatment
7. Osteoarthritis
• 2nd only to CVD in producing
chronic disability that directly
impacts the quality of life
• Causes
– Obesity, genetics, trauma
– More active lifestyles
– Work past retirement age
– Younger population
• #1 Cause of Decreased Work
Performance
8. Osteoarthritis of The Knee
I. Overview
Epidemiology
Definition
Risk Factors
I. Clinical Approach to Knee Pain
II. Differential Diagnosis
III. Diagnosis of Knee OA
IV. Management
Lifestyle
Medical
Surgical
9. Overview: Epidemiology
• Knee OA most common cause of disability in adults
• Decreased work productivity, frequent sick days
• Highest medical expenses of all arthritis conditions
• Symptomatic Knee OA
– More than 10 million Americans 1
– More than 11% of persons > 64yo 2
10. Overview: Definition
Arthritis vs. Arthrosis
Gradual loss of articular cartilage in the knee joint
• 3 articulations:
1) Lateral condyles of the femur and tibia
2) Medial condyles of the femur and tibia
3) Patellofemoral joint
Damage caused by a complex interplay of joint
integrity, biochemical processes, genetics, and
mechanical forces
14. Osteoarthritis of The Knee
I. Overview
Epidemiology
Definition
Risk Factors
I. Clinical Approach to Knee Pain
II. Differential Diagnosis
III. Making The Diagnosis
IV. Management
Lifestyle
Medical
Surgical
15. Clinical Approach to Knee Pain
“Hey Doc, my knee’s been hurting!”
History
• SOCRATES pain questions
• Inflammatory sx e.g. fever, hot joint
• History of trauma or surgery
• Instability
• Functional loss
• Prior treatment
16. Clinical Approach to Knee Pain
Physical Exam
• Vitals, BMI
• Palpation: isolate tenderness, effusion, crepitus
• ROM: measure degree of flexion
• Stability: ligaments, menisci
• Alignment: genu varus or valgus
• Function: gait, duck waddle
17. Clinical Approach to Knee Pain
Valgus Test (MCL) Varus Test (LCL) Lachman Test (ACL)
McMurray Maneuver Duck Waddle
(menisci) (stability)
19. Osteoarthritis of The Knee
I. Overview
Epidemiology
Definition
Risk Factors
I. Clinical Approach to Knee Pain
II. Differential Diagnosis
III. Diagnosis of Knee OA
IV. Management
Lifestyle
Medical
Surgical
20. Differential Diagnosis of Knee Pain
Medial Pain Lateral Pain
• OA • OA
• MCL • LCL
• Meniscus • Meniscus
• Bursitis • Iliotibial band syndrome
Diffuse Pain Anterior Pain
• OA • OA
• Infectious arthritis • Patellofemoral syndrome
• Gout, pseudogout • Prepateller bursitis
• RA • Quadriceps mechanism
21. Osteoarthritis of The Knee
I. Overview
Epidemiology
Definition
Risk Factors
I. Clinical Approach to Knee Pain
II. Differential Diagnosis
III. Diagnosis of Knee OA
IV. Management
Lifestyle
Medical
Surgical
22. Diagnosis of Knee OA
Classic Clinical Criteria
– established by ACR, 1981
– sensitivity 95%, specificity 69%
knee pain plus at least 3 of 6 characteristics:
• > 50 yo
• Morning stiffness < 30 min
• Crepitus
• Bony tenderness
• Bony enlargement
• No palpable warmth 5
23. Diagnosis of Knee OA
Classification Tree
• Clinical symptoms
• Synovial fluid
1. WBC<2000/mm3
2. Clear color
3. High Viscosity No OA
• X-rays
1. Osteophytes
2. Loss of joint space
3. Subchondral sclerosis
4. Subchondral cysts
Confirmed by arthroscopy Sensitivity 94 %;
(gold standard) 6 Specificity 88 %
25. Osteoarthritis of The Knee
I. Overview
Epidemiology
Definition
Risk Factors
I. Clinical Approach to Knee Pain
II. Differential Diagnosis
III. Diagnosis of Knee OA
IV. Management
Lifestyle
Medical
Surgical
26. Guidelines for Managing Osteoarthritis
Surgery
SEVERE OA
COX-2’s Hyaluronic
Acid
High Dose
NSAIDS + Corticosteroids
Gastroprotectant MODERATE
simple analgesics,
low dose NSAID’s
MILD
Exercise, Physical Therapy,
Weight Loss, Orthotics,
Nutraceuticals, Bracing
Adapted from Recommendations for the Medical Management of
Osteoarthritis of the Hip and Knee, ACR, 2000
27. AAOS Clinical Practice Guideline on
the Treatment of OA of the Knee
• Patient Education and Lifestyle Modification
• Rehabilitation
• Mechanical Interventions
• Complementary and Alternative Therapy
• Pain Relievers
• Intra-articular Injections
• Needle Lavage
• Surgical Intervention
29. AAOS Treatment of OA of the Knee:
Patient Education, Lifestyle Modification, Rehabilitation
• Lifestyle
modification
• Exercise
• Physical therapy
• Weight loss
30. AAOS Treatment of OA of the Knee:
Patient Education, Lifestyle Modification, Rehabilitation
• Maintain healthy physical
activity
– Physical, emotional health
benefits
– Reduce risks
• CVD
• Weight gain
• Diabetes
– Home exercise and supervised
exercise class
• McCarthy et al, Health Tech
Assess ‘04
33. Management: Medical
• Glucosamine/Chondroitin
– 1500 mg/1200 mg daily ($40-50/month)
– Glucosamine: building block for glycosaminoglycans
– Chondroitin: glycosaminoglycan in articular cartilage
– GAIT study, NEJM, Feb 23, 2006
• Multicenter, double blind, placebo-controlled, 24 wks, N=1583
• Symptomatic mild or moderate-severe knee OA
• Infrequent mild side effects e.g. bloating
• For mild OA, not better than placebo
• For moderate-severe OA, combination showed benefit 8
– Patient satisfaction
34. Management: Medical
• Acetaminophen
– Indication: mild-moderate pain
– 1000 mg Q6h PRN
– Better than placebo but less efficacious than NSAIDs 9
– Caution in advanced hepatic disease
• NSAIDs
– Indication: moderate-severe pain, failed acetaminophen
– GI/renal/hepatic toxicity, fluid retention
– If risk of GIB, use anti-ulcer agents concurrently
– Agents have highly variable efficacy and toxicity
35. Management: Medical
• Opioid Analgesics
– Indication:
• Moderate-severe pain
• Acute exacerbations
• NSAIDs/Cox-2 inhibitors failed or contraindicated
– Oxycodone synergistic w/ NSAIDs 13
– Tramadol/acetaminophen vs codeine/acetaminophen
• Similar pain relief 14
– Avoid long-term use
– Caution in elderly
• Confusion, sedation, constipation
36. Management: Medical
Intraarticular Injections
• Glucocorticoids
– Indication: pain persists despite oral analgesics
– 40 mg/mL triamcinolone (kenalog-40)
– Solution: 5 mL (lidocaine 4 mL + kenalog 1 mL)
– Limit to Q3months, up to 2 yrs
– Effective for short-term pain relief < 12 wks
– Acute flare w/in 48 hrs post-injection 15
37. Management: Medical
Intraarticular Injections
• Hyaluronans (e.g. Synvisc)
– Indication: pain persists despite other agents
– Synthetic joint fluid
– Pain relief similar to steroid injections
– 2 mL injection Qwk x 3, $560-760/series
– Medicare reimburses 80%, Medi-cal $455.90
– 60-70% patients respond, relief up to 6 months
– Patient satisfaction 16, 17
38. Contraindications
Overlying cellulitis*
Severe coagulopathy
Anticoagulant therapy
Septic effusion
More than three injections per year in a weight-bearing joint
Lack of response after two to four injections
Bacteremia*
Unstable joints
Inaccessible joints (i.e. facet joints of spine)
Joint prosthesis*
Evidence of surrounding osteoporosis
Recent intra-articular joint osteoporosis
History of allergy or anaphylaxis to injectable pharmaceuticals
*absolute contraindications
Adapted from Pfenninger, 1991 and Cardone, 2002
39. Pharmacologic Agents
• Corticosteroids
– Modify local inflammatory response
– Increase viscosity of synovial fluid
– Alter production of hyaluronic acid synthesis
– Change synovial fluid leukocyte activity
Short-term benefit of intra-articular corticosteroids in
treatment of knee OA well established; longer term
benefits not confirmed.
Cochrane Collaboration, 2006
40. Hyaluronan is usually not a first line
treatment for knee osteoarthritis
• Typically, hyaluronan injections (also
sometimes called viscosupplements) are
recommended for patients who have not
found adequate pain relief from more
conservative treatment options:
41. • Although, hyaluronan injections are not usually
recommended before trying other
treatment options, the best result usually occurs
if the patient is in the early stages of
osteoarthritis
• Patients in the later stages of osteoarthritis, who
may be waiting for knee replacement surgery,
are considered good candidates for hyaluronan
injections so they hopefully can get some relief
while waiting.
•
42. Among patients who were helped by hyaluronan
injections, when pain relief occurred was variable
• The most significant pain relief occurred 8 to 12
weeks after the first injection for most patients.
Studies have shown that Synvisc and Hyalgan
provide pain relief from knee osteoarthritis for up to
six months, with some patients getting relief for an
even longer duration. Supartz was shown in studies
to provide pain relief for up to 4 1/2 months after the
fifth injection.
• Patients may be able to repeat the course of
treatment with hyaluronan injections. For example, a
patient who has experienced up to six months of
pain relief from Synvisc but has had pain return may
be a candidate for another course of Synvisc
injections.
43. Available
• Hyalgan - May 28, 1997
• Synvisc - August 8, 1997
• Osflex - January 24, 2001
• Lydium – Pharos 2005
• Durolane 2006
• Synvisc-One - February 26, 2009
• Dualvisk 2010
44. Management: Medical
Intraarticular Injections
• Technique
– 22 gauge 1.5 inch needle
– Approach accuracy:
• Lateral mid-patellar 93% 18
– Patient supine
– Leg straight
– Manipulate patella
– Angle needle slightly posteriorly
– Inject after drop in resistance or fluid aspirated
45. Who is a candidate for Viscosupplemenation?
• Poor responders to conservative
treatments like OTC pain relievers and
physical therapy
• Active patients with mild to moderate OA
• Patients that cannot tolerate oral NSAIDs
– 16,500 GI bleed-related deaths/year
• Patients too young, heavy and/or not
ready for arthroplasty
46. To minimize potential side effects, after
an injection patients should avoid
strenuous activities for 48 hours
The most common side effects around the
injected joint, which are usually mild,
include:
• temporary injection site pain
• swelling
• redness and warmth
• itching
• bruising
47. There are important safety factors to
consider before using hyaluronan injections
Patients wishing to try Synvisc, who are
allergic to bird products (i.e., feathers,
eggs or poultry), should talk to their
doctor. Patients should also make their
doctor aware of legs which are swollen or
infected. Also, hyaluronan injections have
not been tested in children, pregnant
women, or nursing mothers.
48. What Is Synvisc-One ?
• Synvisc-One is a single injection viscosupplement
approved in the United States for the treatment
of knee osteoarthritis. Synvisc-One became FDA-
approved on Feb. 26, 2009. It is manufactured
and marketed by Genzyme Corp.
• Synvisc - the original formula - was FDA-approved
in 1997. It is administered as a series of three
weekly 2 milliliter injections (for a total of 6 ml).
Both Synvisc and Synvisc-One contain the same
material (hylan G-F 20) as well as the same total
treatment volume. But, Synvisc-One delivers the 6
ml of hylan G-F 20 in a single injection.
49. Synvisc-One as an Osteoarthritis
Treatment
Synvisc-One can be used for patients with
knee osteoarthritis pain who have not
been sufficiently helped by conservative
non-drug treatments and simple
analgesics like acetaminophen. Patients
being treated with Synvisc-One can
achieve up to 6 months pain relief.
50. Warnings and Precautions for
Synvisc-One
Patients with a known previous serious reaction to
hyaluronan, the active ingredient in Synvisc and
related products, should not be treated with Synvisc-
One. Patients with infection in or around the affected
knee should not be injected. Patients who are allergic
to bird proteins, feathers, or egg products or those with
venous or lymphatic problems in the leg should be
treated cautiously. Likewise, for patients with severe
inflammation in the knee.
Common adverse events associated with Synvisc-One
included mild to moderate arthralgia, arthritis, injection
site pain, and joint effusion. No serious adverse events
were reported.
51. Advice for Patients Treated With
Synvisc-One
• After injection with Synvisc-One, you
should avoid strenuous activity, including
prolonged weightbearing activities, for
about 48 hours after treatment.
53. Management: Surgical
When to Refer
• Knee pain or functional status
has failed to improve with
non-operative management
Types of Procedures
• Arthroscopic Irrigation
• Arthroscopic Debridement
• High Tibial Osteotomy
• Partial Knee Arthroplasty
• Total Knee Arthroplasty
54. Conclusions: AAOS Clinical Practice
Guidelines on the Treatment of OA of the Knee
• OA is becoming more frequent as
population is more active and lives
longer
– 581,000 TKR annually in US (AAOS)
• Diagnosis, indications and patient
expectations are paramount to
success
– Improved pain relief and functionality
• Higher quality evidence is needed for
treatments up to but not including
arthroplasty
Craig S. Radnay, M.D. 03/01/13 30-40% of population by age 65
Craig S. Radnay, M.D. 03/01/13 Increased # of falls, with balance issues
Weight loss is most important modifiable risk factor OA association with activities, muscle weakness not as strong
OA sx: gradual onset, pain (most common medial 70%), stiffness, gelling, alleviated by rest R/O infectious arthritis
Important to isolate tenderness for correct dx Duck waddle for function
Lachman more sensitive than ant drawer McMurray: positive test if pain or click with motion
Weight-bearing/standing AP views important to assess for loss of jt space
Medial: -Medial Knee OA 70% of cases -Anserine bursitis (most common bursitis, often B)dx: TTP quarter-sized area tibial plateau 1-1.5 inches below jt line, pain at motion/rest/night) -Bursa adjacent to MCL Lateral: -IT band (TTP over lateral femoral condyle) Anterior: -PF syndrome (most common cause of knee pain < 45yo, female, often B, compress patella to femur) Diffuse -inflammatory (limited ROM, knee kept slightly flexed) -50% of Nongonococcal bacterial arthritis cases involve the knee
4 of these are exam findings
Improved specificity with x-rays, fluid sample
X-ray on right: Top arrow – subcondral cyst Middle arrow – osteophytes Bottom arrow – subchondral sclerosis
Weight loss Exercise program If unclear about insoles vs braces, early referral to podiatry or orthopedics or sports medicine
Craig S. Radnay, M.D. 03/01/13
What comes first? Snowball effect Depicts correction of R knee varus deformity. Unloads medial compartment. Unloader braces can correct up to 3 degrees
NSAIDS > Tylenol > placebo: 2004 meta-analysis of 10 randomized trials. NSAIDs: caution in CHF, HTN (fluid retention)
Lidocaine tells you if in the joint Can extend injection duration if inevitably going towards total knee replacement
Anterolateral approach 71%, anteromedial 75% Doug Jackson studied accuracy of injections by orthopods by any approach, <50% on first try.