osteoarthritis diagnosis and management

Rachmat Gunadi Wachjudi

Lahir di Garut, 16-1-1955Lahir di Garut, 16-1-1955PendidikanPendidikan 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 Foundation FK UI Jakarta & Arthritis Foundation

of WAof WAPekerjaan:Pekerjaan: Ka Div Ka Div Reumatologi RS Dr Hasan SadikinReumatologi RS Dr Hasan SadikinOrganisasi ProfesiOrganisasi Profesi IDI, IDI, IRA, PAPDI, PEROSI, PERALMUNIIRA, PAPDI, PEROSI, PERALMUNI, APLAR, , APLAR,

IPSIPS

OsteoarthritisA Comprehensive

management

The Coming Epidemic of ARTHRITIS. 160[24]. 9-12-2002. Time Magazine.

Arthritis: the most common is Osteoarthritis

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.

Rheumatic ailments

1%

1%

6%

4%

4%

69%

3%2%

10%

Osteoarthritis

SLE

Rheumatoid Artritis

Gouty Artritis

Sp Arthritis

Systemic Sclerosis

Osteoporosis

Soft TissueRheumatism

others

33,2%

6,8%

1,2%1,1%

1%

Rheumatic diseases

slide 8

Vicious Cycles in Osteoarthritis (OA)

Imbalance of...Cytokines

Prostaglandin E2

Cartilage matrix fragmentsFree radicals

Proteolytic enzymesProtease inhibitors

Proteolytic destruction of cartilage matrix

Altered mechanical loading of cartilage and

ligaments

Remodeling of Bone

osteophytosis, subchondrial

sclerosisPhasic synovial

Inflammation & angiogenesis

Peripheral & central sensitization

pain

Impaired mobility:Reduced exercise, muscle weakness,

joint laxity

Aet

iolo

gy

/ Ris

k fa

ctors

Diseas e / O

utco

me

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

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)

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)

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

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.

Hand OA Heberden’s nodes (DIP)

Bouchard’s nodes (PIP)

04/08/1504/08/15 RGW IRA BandungRGW IRA Bandung 1717

Goals of Arthritis managementGoals of Arthritis management

• Relieve pain/inflammation Relieve pain/inflammation

• Minimize risks of therapyMinimize risks of therapy

• Retard disease progressionRetard disease progression

• Provide patient educationProvide patient education

• Prevent work disability Prevent work disability

• Enhance quality of life and functional Enhance quality of life and functional independence independence

Treatment Principles

• Non-Pharmacologic– Education– Physiotherapy

• Exercise program• Pain relief modalities

– Aids and appliances

• Pharmacologic– Medical Treatment

• Surgical Treatment• Complementary and Alternative Medicine

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.

Pharmacologic therapy

• Analgesic and anti-inflammatory

• Intra-articular corticosteroids

• Intra-articular hyaluronic acid

• Disease modifying Osteoarthritis Drugs

Treatment ConsiderationsFirst, perform a First, 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)

Disease modifying Osteoarthritis Drugs

• Nutraceuticals

• Diacerein

• SOD ?

• Hyaluronan ?

• Doxy/Minocyclin

Nutraceuticals

• Glucosamine

• Chondroitin

• Glucosamine + Chondroitin ?

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

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)

Calcitonin & Estrogen

• memiliki efek proteksi terhadap erosi permukaan kartilago sendi secara bermakna.

• DMOAD di masa mendatang ?

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

• 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.

Rose hips

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

slide 32

* 3 weeks of rosehip treatment resulted in a significant reduction in pain when compared to placebo (p<0.014)

Delt

a D

ecr

ease

: D

elt

a I

ncr

ease

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

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)

Delt

a D

elt

a D

ecr

ease

: I

ncr

ease

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)

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

% R

esp

on

ders

Rosehip

*

Placebo

Sub-study analysis of Rein et al. Phytomedicine 11(5): 383-391 (2004)

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.

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