#177 Osteoarthritis Master Class with Tuhina Neogi MD, PhD

October 14, 2019 | By Matthew Watto, MD

Osteoarthritis guidelines author, Dr. Tuhina Neogi schools us on all things OA, including your questions from Twitter

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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Credits

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

Partners

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Time Stamps

• 00:00 Sponsor: ACP’s National Internal Medicine Day I.M. Proud Story Contest
• 00:15 Cold open, disclaimer, intro and guest bio
• 05:44 Guest one-liner, Picks of the Week*: Joe Nesbo mystery novels, The Snowman (film), Midsommar (film), Won’t You Be My Neighbor (film), @vermontkitchen Beth’s food blog, Serious Eats; Buy Yourself a Ballistic Jump Rope
• 07:55 Dr. Neogi’s Women in Medicine moment of awakening
• 15:40 Sponsor: ACP’s National Internal Medicine Day I.M. Proud Story Contest
• 17:35 Case of Osteoarthritis; Initial history and exam
• 23:23 Imaging for osteoarthritis
• 28:45 Physical exam for OA
• 31:45 Osteoarthritis risk factors
• 33:48 Pathophysiology of OA
• 37:43 Targeted therapies for OA are in the pipeline; Weight loss and joint protection
• 41:35 Mechanisms of pain in OA and recognizing pain phenotypes
• 46:58 Mainstays of osteoarthritis treatment
• 49:56 Capsaicin, Acetaminophen, and the importance of positivity
• 52:22 Intra-articular injections with corticosteroids or hyaluronic acid
• 57:25 Occupational therapy, More on Topical and Oral NSAIDS; SNRIs (duloxetine)  
• 62:00 Questions from Twitter: CBD and marijuana (cannabis), turmeric, fish oil (omega 3 fatty acids)
• 65:03 More from Twitter: Glucosamine/chondroitin, acupuncture, tai chi, yoga, mindfulness, meditation
• 70:42 New targets for osteoarthritis; Take Home Points
• 73:40 Outro

Dr. Neogi’s Take Home Points

“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

1. Joint pain and musculoskeletal pain are some top reasons why people come to see their physicians.
2. Watch out for signs of inflammatory arthritis and systemic autoimmune disease (e.g. morning stiffness beyond 30 minutes, joint swelling and improvement of pain with exercise)
3. First line therapy for osteoarthritis should include: patient education, a walking program, weight/nutrition management, and referral to physical therapy.

Osteoarthritis Show Notes

KP = Kashlak Pearls

Diagnosis of Osteoarthritis (OA)

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)

Physical exam

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)

Red Flags

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.

Pathophysiology

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 in OA

Mechanisms of Pain

Pain is caused by more than just peripheral nociceptive pain. Eventually, peripheral neuropathic pain and central pain sensitization also occur. (Hunter, 2019)

Differentiating Types of Pain

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.

Assess Patients for Yellow flags 

The yellow flags (traditionally applied to back pain) are psychosocial factors shown to be indicative of long term pain and disability (Samanta, 2003):

• A negative attitude that back pain is harmful or potentially severely disabling
• Fear avoidance behaviour and reduced activity levels
• An expectation that passive, rather than active, treatment will be beneficial
• A tendency to depression, low morale, and social withdrawal
• Social or financial problems

Treatment of Osteoarthritis

Core  nonpharmacologic treatments for OA

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

Topical capsaicin

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!

Acetaminophen

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 NSAIDS

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). 

Oral NSAIDS

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).

Duloxetine

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 injections

Corticosteroids

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 (“Viscosupplementation”)

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).

Questions from Twitter

Cannabidiol (CBD) for osteoarthritis

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

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

Fish oil has been promising in some early trials (Akbar, 2017).

Glucosamine and Chondroitin

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.

Mind Body Therapies for Osteoarthritis

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)

Goal

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.

Learning objectives

After listening to this episode listeners will be able to…

1. Differentiate OA from other joint pathologies like rheumatoid arthritis
2. Diagnose osteoarthritis and select patients who warrant imaging or labs
3. Describe the pathophysiology of osteoarthritis
4. Counsel patients on appropriate lifestyle modifications for management of OA symptoms
5. Choose appropriate pharmacotherapy for osteoarthritis and counsel patients about potential risks and benefits
6. Counsel patients about supplements and complementary, alternative medicine therapies commonly suggested by popular culture

Links*

Any articles mentioned on the show are linked in the text above as Author, Publication date. Note: hyperlinks contain PubMed ID).

1. Dr Neogi recommends Joe Nesbo mystery novels 
2. Paul says this film, The Snowman, based on Joe Nesbo’s book is so bad that you need to see it.
3. Paul recommends watching, Midsommar (film). Beth and Dr Neogi warn that it’s terrifying. 
4. Beth says the film, Won’t You Be My Neighbor (film) will warm your heart,
5. Paul recommends that everyone follow Beth’s food blog and instagram account, @vermontkitchen
6. Beth recommends Serious Eats and making cobbler
7. Watto recommends getting a Ballistyx jump rope. Thanks to @hannahrabrams!

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Please feel free to reproduce, share and/or edit these wonderful show notes and figures! Just give us credit! Love, The Curbsiders Team                

Disclosures

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. 

Citation

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.