Osteoarthritis Diagnosis and management
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Transcript of 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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