American College of Rheumatology (ACR) osteoarthritis guidelines author, Dr. Tuhina Neogi (Boston University; @Tuhina_Neogi ) schools us on all things OA, including new understandings of pathophysiology, diagnosis, when to order imaging and labs, and an overview of pharmacologic and nonpharmacologic therapies. Plus, get answers to your questions from Twitter on CBD, turmeric, glucosamine, chondroitin, NSAIDS, intra-articular steroid and hyaluronic acid injections, tai chi, and more!
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Written (including CME questions) and Produced by: Beth Garbitelli and Matthew Watto MD, FACP
Cover Art and Infographic by: Beth Garbitelli
Hosts: Beth Garbitelli, Matthew Watto MD, FACP; Paul Williams MD, FACP
Editor: Matthew Watto MD, FACP
Guest: Tuhina Neogi MD, PhD
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“It’s not just a disease of cartilage and bone. It’s a disease of the whole joint. And I think if we were to name this disease today this would be total joint failure”Dr. Tuhina Neogi
KP = Kashlak Pearls
A diagnosis of OA can be made on history and exam alone. Typical symptoms include pain with weight bearing (aka joint loading) and worsening of pain with activity. Imaging is NOT required in most cases. Plain radiographs are insensitive and often discordant with the degree of symptoms across a population i.e. a patient with a horrible x-ray might have no symptoms while another patient with normal imaging might have severe pain (Bedson, 2008). That said, Dr Neogi’s study from 2009 found that within a given patient, severity of radiographic disease did predict pain experience (Neogi, 2009).
KP: Imaging is NOT required for the diagnosis of osteoarthritis. It may be considered for atypical symptoms or when an alternate diagnosis is suspected. (Hunter, 2019)
Observe the patient’s gait. Note the alignment of their joints. Examine the joint above and below the affected joint.
Classic findings include: crepitus, restricted or painful movement, joint line tenderness, and bony enlargement. (Hunter, 2019)
Ask about the following red flags, which suggest an inflammatory arthritis (e.g. rheumatoid arthritis): morning stiffness longer than 30 min, joint swelling, or pain that improves with activity.
KP: OA is not a normal part of aging! –Dr. Neogi
Dr. Neogi points out that osteoarthritis is largely bio-mechanically driven, “some event leads to catabolic forces outpacing anabolic healing mechanisms within the joint”. It’s not a passive degenerative disease or just simple “wear-and-tear”. (Hunter, 2019)
Osteoarthritis is a whole joint disease, involving structural alterations in the cartilage, subchondral bone, ligaments, capsule, synovium, and periarticular muscles (Hunter, 2019).
Figure 2 in this paper by Hunter has a nice synopsis of the complex signalling pathways and structural changes that occur osteoarthritis develops.
Pain is caused by more than just peripheral nociceptive pain. Eventually, peripheral neuropathic pain and central pain sensitization also occur. (Hunter, 2019)
Dr. Neogi evaluates each patient’s sleep and mood. On exam, she checks for pain, or tender points in nonarticular areas (as found in fibromyalgia). Patients with central pain sensitization can often be identified when their pain symptoms are discordant to their degree of joint damage. Yellow flags might also be present and predict a poor prognosis (more on these below). These patients benefit from multi-targeted interventions that target neuropathic and/or central pain rather than just peripheral nociceptive pain (Clauw, 2017).
KP: Neuropathic and central pain can often be identified in patients with pain symptoms out of proportion to their degree of joint disease. Be sure to target sleep and mood as part of a multimodal approach –Dr. Neogi’s expert opinion.
The yellow flags (traditionally applied to back pain) are psychosocial factors shown to be indicative of long term pain and disability (Samanta, 2003):
Patient education, self management, exercise (e.g. walking program, basic strength training), weight loss, and physical therapy are the mainstays of therapy (Hochberg, 2012 ACR Guidelines on OA). Occupational therapy may be helpful for hand OA, but Dr. Neogi points out a gap in high quality trials to confirm benefit.
Osteoarthritis Research Society International (OARSI) guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis can be a helpful resource (Bannuru, 2019). Dr Neogi is authoring the upcoming American College for Rheumatology (ACR) guidelines which should be out in 2020.
Dr. Neogi referenced this NPR segment from the OA Action Alliance on Exercising to Ease Pain: Taking Brief Walks Can Help –September 23, 2019
Capsaicin can be tried for hand OA, but was not guideline recommended for knee or hip (Hochberg, 2012). Downsides to capsaicin include the need for multiple applications and burning sensation. Be sure to wear gloves and avoid use on mucous membranes, especially the eyes and genitals. Ouch!
The use of acetaminophen for OA has minimal efficacy in multiple meta-analyses (Machado, 2015; Bannuru, 2015; da Costa, 2017). The 2019 OARSI guidelines recommend avoiding use (Bannuru, 2019). All that said, Dr. Neogi notes it’s reasonable to try when other options (i.e. NSAIDS) are limited by co-morbidities —expert opinion.
Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with knee OA and conditionally recommend for polyarticular OA in the 2019 OARSI guidelines (Bannuru, 2019). The 2012 ACR guidelines have a weak (“conditional”) recommendation for use of topical NSAIDS for both hand OA and knee (Hochberg, 2012). In general large reviews have shown topical NSAIDS to be safe, superior to placebo, and comparable to oral NSAIDS (Barthel, 2010; Derry, 2016). It should be noted that the response rates to topical placebo are double those of oral placebo (Derry, 2016).
The use of oral NSAIDS use is limited by comorbidities, especially concerns of cardiac and gastrointestinal side effects (Pelletier, 2016). Real and theoretical renal concerns also exist, especially for patients with chronic kidney disease and those taking diuretics and ACE inhibitors or ARBs (see episode #69 notes with Dr Joel Topf for details).
The 2019 OARSI guidelines for OA give oral NSAIDS a conditional (weaker) recommendation for use with the caveats that a) patients with gastrointestinal disease should use a non-selective NSAID along with a proton pump inhibitor or a COX-2 inhibitor; and b) Oral NSAIDS are not recommended for patients with cardiovascular comorbidities or frailty (Bannuru, 2019).
SNRIs like duloxetine may also add benefit (Chappell, 2011; Wang, 2015), and duloxetine is FDA approved for the management of chronic musculoskeletal low back pain and knee osteoarthritis. Dr. Neogi considers duloxetine for patients with widespread pain and mood symptoms –expert opinion.
Intra-articular steroid injections remain controversial. A 2015 Cochrane review notes low quality data for short term benefit, but uncertain benefit beyond 6 months (Jüni, 2015). A more recent trial of intraarticular corticosteroids versus saline found both no lasting effect on pain after two years of therapy (McAlindon, 2017). McAlindon et al also observed cartilage loss in the corticosteroid injection group, though we don’t yet know if this concern has clinical significance.
Hyaluronic acid (HA) injections remain very controversial. No benefit was seen in a systematic review of randomized, sham controlled trials (versus placebo), and any trials showing benefit were nonblinded or improperly blinded (Jevsevar, 2015). A more recent trial found no difference in efficacy between intraarticular corticosteroid injections and HA derivatives (Tammachote, 2016) with editorialists noting the far cheaper cost of corticosteroids.
Despite it all, the OARSI consensus guidelines include hyaluronic acid derivatives as a low consensus recommendation targeting benefit beyond 12 weeks (Bannuru, 2019). The 2013 Orthopedic Surgery guidelines recommend against the use of intra-articular HA (Jevsevar, 2013).
There is limited evidence of benefit with use of CBD. One trial using transdermal CBD in rats suggested reduced pain and inflammation without side effects (Hammell, 2016). A more recent update on the use of cannabis-based pharmaceuticals for pain found that the quality and clinical significance of the available evidence is too limited to make a strong recommendation in favor of the routine clinical use (Urits, 2019). Check out the Curbsiders prior episode on medical marijuana for more information (Curbsiders 2017).
Turmeric binds to receptors on the joint, but we lack adequate info on route and dosing. Additionally, Dr. Neogi points out that supplements are not regulated so patients cannot know which dose they are getting.
Fish oil has been promising in some early trials (Akbar, 2017).
Dr. Neogi notes that well conducted, non-industry sponsored trials of glucosamine / chondroitin have failed to show benefit in meta-analyses (Towheed, 2005; Vlad, 2007; Wandel, 2010 ). She does not routinely recommend their use, and counsels patients that the biggest risk is to their wallet –expert opinion.
Dr. Neogi routinely discusses management of stress and mood symptoms with her patients. She recommends a trial of mind/body therapies like mindfulness and meditation. Mindfulness based stress reduction (MBSR) as complementary therapy for various chronic, painful conditions (Details at this NIH site https://nccih.nih.gov/taxonomy/term/228).
The following mindfulness apps were recommended on the show —Headspace (Free trial, AMA members get 2-year free membership), Insight Timer (Free).
Tai chi also seems to help with pain and physical function for patients with knee osteoarthritis. (Wang, 2009; Escalante, 2010)
Listeners will learn to classify osteoarthritis (OA), assess symptom management, counsel patients on lifestyle modifications, manage pharmacologic interventions for OA, and counsel patients about complementary and alternative therapies commonly suggested by popular culture.
After listening to this episode listeners will be able to…
Any articles mentioned on the show are linked in the text above as Author, Publication date. Note: hyperlinks contain PubMed ID).
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Dr Neogi has acted as a consultant to Pfizer and Novartis for osteoarthritis therapies still in clinical trials. No trade names were used during the podcast and a balanced range of therapeutic options was included in the discussion. The Curbsiders report no relevant financial disclosures.
Neogi T, Garbitelli B, Williams PN, Watto MF. “#177 Osteoarthritis Master Class with Tuhina Neogi MD, PhD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. October 14, 2019.
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Great episode with Dr Tuhina Neogi - OA
Can you please provide link to study of one knee versus other knee pain and correlation with structural findings? Thanks!