The ten minute management of osteoarthritis

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The ten minute management of osteoarthritis

• Managing OA in Primary Care
• maximising patient consultation time

Supported by an educational grant from Merck
Sharp Dohme Limited
2

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Osteoarthritis burden of disease

• One in five people in the UK have arthritis1
• Arthritis is the largest single cause of physical
  disability in the UK2
• Osteoarthritis (OA) is the most common form of
  arthritis3
• OA is associated with considerable burden of
  disease second only to cardiovascular disease
  in causing severe disability3

4
OA in Primary Care

• Most patients with OA are managed in Primary
  Care4
• Overall, muscloskeletal problems account for one
  in ten (10) of General Practice consultations4
• GPs have an opportunity to optimise patient care
  in OA

5
Key principles5 EULAR guidelines

• 1. Treatment should be tailored to the patient
• 2. The relationship between the healthcare team
  and the patient should be a two-way process
• 3. Using tools can help to assess the patients
  pain and disability
• 4. Patient education has a significant impact on
  pain management
• 5. Treatment should be a combination of
  non-pharmacological and pharmacological
  measures

6
Management options5 EULAR guidelines

• 6. Non-pharmacological management strategies
  should be incorporated
• 7. Paracetamol and NSAIDs should be used as
  first-line pharmacotherapy
• 8. There is evidence to support the use of some
  symptomatic slow-acting drugs for OA (SYSADOA)
• 9. Corticosteroid intra-articular injections can
  be useful in acute exacerbations
• 10. Consider surgery in patients unresponsive
  to medical management

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Key principle 1Patient-tailored treatment

• OA is a long-term, chronic condition and has a
  considerable impact on quality of life5
• Treatment should
• be tailored to the patient5
• consider the individual patients needs in terms
  of both functionality and of pain relief5
• It is likely that each individual patient will
  have to try a number of management options before
  finding the combination which works best for them5

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Key principle 2 Doctor/patient relationship5

• The relationship between the healthcare team and
  the patient is key
• The patient should be an active partner in
  disease management
• Involve the patient in treatment decisions and
  listen to their concerns
• The patient is an expert in their disease they
  know their pain better than anyone else and will
  have developed strategies to deal with it

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Key principle 3Using tools

• Tools can help to assess the patients pain and
  disability
• Tools include
• rating scales
• questionnaires6
• pain diagrams
• Using tools before and after treatment is also
  useful to determine whether treatment
  is working

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Pain drawings

• Mark the area on your body where you feel the
  described sensations
• Use the appropriate symbol
• Mark the areas of radiation
• Include all affected areas
• Numbness
• Pins and needles Burning
  xxxxxxxx
• Stabbing / / / / / / /

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Rating scales

• Visual analogue scale

No pain
Worst possible pain

• Pain intensity
• 0 No pain ?
• 1 Mild ?
• 2 Discomforting ?
• 3 Distressing ?
• 4 Horrible ?
• 5 Excruciating ?

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Key principle 4Patient education

• Studies suggest that education is around 20 as
  effective as NSAIDs, and can have a synergistic
  effect with other treatments8
• Patient information and self-management
  strategies can empower patients to take control
  of their arthritis
• Effective education techniques include
• individual education packs
• regular telephone calls
• group education
• patient coping skills
• spouse assisted coping skills training5

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Arthritis Care

• Arthritis Care, 18 Stephenson Way, London, NW1
  2HD
• Telephone [phone] (switchboard)
• Fax [phone]
• www.arthritiscare.org.uk
• Helpline
• Freephone 0808 800 4050 Monday-Friday,10 am - 4
  pm
• Email Helplines_at_arthritiscare.org.uk

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Arthritis Care

• Arthritis Care is the UKs largest voluntary
  organisation working with and for all people with
  arthritis. It provides information and support on
  a range of issues related to living with
  arthritis. Arthritis Care campaigns locally and
  nationally to make sure people with arthritis
  have access to the treatments and services they
  deserve. In summary, we provide
• Helplines, support and courses to help patients
  manage their arthritis
• Information and booklets on issues from benefits
  to treatments
• A network of local information and support
• Campaigns to change attitudes and laws to improve
  quality of life for those with arthritis
• Self-management courses including Challenging
  Arthritis and the Positive Future workshops aimed
  at younger people

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Arthritis Care FactSheets

• A full list of factsheets are available on the
  Arthritis Care website. Some of the factsheets we
  have are mentioned below
• Home treatment for pain relief heated pads and
  cold packs
• TENS machines An electronic method of pain
  relief
• Resources to help you exercise
• Resources to help you manage your pain
• COX-2 drugs a patient question and answer sheet
• Osteoarthritis of the hip

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Key principle 5Management options

• Treatment should be a combination of
  non-pharmacological and pharmacological measures5
• Indirect evidence suggests non-pharmacological
  treatments offer additional benefits over and
  above treatment with NSAIDs and analgesics5

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Management option 6Non-pharmacological management

• Life-style modification has an important role in
  management5,9
• For example5
• weight loss
• exercise
• quadriceps strengthening
• range of movement
• general fitness
• hydrotherapy
• assistive devices (canes and frames)
• appropriate footwear, insoles

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Management option 6 Non-pharmacological
management

• Little formal evidence to support complementary
  therapies, but some patients derive considerable
  benefit
• Examples of complementary therapies include
• Acupuncture Alexander technique
• Aromatherapy Chiropractice
• Hydrotherapy Massage
• Osteopathy Reflexology
• Tai chi

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Management option 6 Non-pharmacological
management

• Self-management strategies can improve patients
  ability to manage their pain and disability of
  OA5
• Access to patient organisations and support
  groups which provide help and advice

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Management option 7Analgesia and NSAIDs

• Use paracetamol as first-line therapy5
• It is likely that the majority of patients will
  have already tried over-the-counter paracetamol5
• In those patients with a poor response to
  paracetamol, NSAIDs should be considered5
• NICE guidance recommends that COX-2 selective
  inhibitors should be considered only in patients
  who may be at high risk of developing serious
  gastro-intestinal (GI) adverse events10
• The European Medicines Agency advised doctors
  that Cox-2 selective inhibitors should only be
  prescribed to people with arthritis at the
  lowest effective dose for the shortest possible
  duration. (EMEA 27 June 2005)

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Management option 7 (1)COX-2 selective
inhibitors

• Consider in patients who may be at high risk of
  developing serious GI adverse events, and in whom
  an NSAID is clearly indicated10
• High-risk patients include, those
• aged 65 years and over,
• with a previous clinical history of
  gastroduodenal ulcer, GI bleeding or
  gastroduodenal perforation. The use of even a
  COX-2 selective agent should be considered
  especially carefully in this situation,
• taking concomitant medication(s) that are known
  to increase the likelihood of upper GI adverse
  events (eg corticosteroids, anti-coagulants)
• See over for updated Cox-2 prescribing guidelines

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Management option 7 (2)COX-2 selective
inhibitors

• June 2005 The European Medicines Agency
  reviewed Cox-2 selective inhibitors, they
  concluded that
• the risks of potential fatal skin reactions with
  Valdecoxib (Bextra) outweighed the benefits and
  suspended Valdecoxib for a year, pending a
  review. Pfizer voluntarily withdrew Valdecoxib
• other Cox-2 selective inhibitors (Celecoxib,
  Etoricoxib, Lumiracoxib, Parecoxib) will have
  stronger guidelines for prescription
• Cox-2s should not be prescribed to people with
  ischaemic heart disease, cerebrovascular disease
  or peripheral arterial disease
• caution when prescribing Cox-2s to people with
  heart disease, hypertension, hyperlipidaemia
  (cholesterol), diabetes and smokers
• doctors are advised to prescribe the lowest
  effective Cox-2 dose for the shortest possible
  duration

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Management option 8Symptomatic slow-acting drugs
of OA

• Symptomatic slow-acting drugs of OA (SYSADOA)
• glucosamine
• chondroitin
• hyaluronic acid
• Supported by increasing evidence, although
  further research is still required5,8,11,12
• Given that these agents appear to be well
  tolerated and do show some benefit their use
  should be considered13

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Management option 9Corticosteroid injections

• Corticosteroid intra-articular injections may be
  used in the management of patients with OA of the
  knee5
• Provide superior short-term efficacy (2-4
  weeks) versus placebo8
• Recommended for acute exacerbations5

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Management option 10Surgery

• Refer for orthopaedic evaluation if patient is
  disabled by OA or in pain unrelieved by medical
  management5,9
• Joint replacement can be very effective5
• Newer techniques such as metal-on-metal
  resurfacing are less invasive15
• Patients should be made aware of the risks and
  benefits of surgery

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Other useful resources

• Arthritis Research Campaign
• http//www.arc.org.uk
• Primary Care Rheumatology Society
• http//www.pcrsociety.com
• British Society for Rheumatology
• http//www.rheumatology.org.uk
• The European League Against Rheumatismhttp//www.
  eular.org
• National Library for Health Musculoskeletal
  Library
• http//libraries.nelh.nhs.uk/musculoskeletal
• Primary Care Question Answer Service
• http//www.clinicalanswers.nhs.uk/index.cfm

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References 1-9

• 1. Arthritis Care. 1 in 5 The prevalence and
  impact of arthritis in the UK (Research report).
  February 2002.
• 2. Disability Care and Mobility Quarterly
  Statistical Enquiry - Disability Living
  Allowance, Attendance Allowance and Invalid Care
  Allowance. Dept of Work and Pensions 2002.
• 3. Watson M. Management of patients with
  osteoarthritis. Pharm J 1997259296-297.
• 4. Royal College of General Practitioners OPCS
  Department of Health and Social Security.
  Morbidity statistics from General Practice.
  Fourth National Survey 1991-1992. HMSO, 1996.
• 5. Jordan KM, Arden NK, Doherty M et al. EULAR
  recommendations 2003 an evidence based approach
  to the management of knee osteoarthritis Report
  of a task force of the Standing Committee for
  International Clinical Studies Including
  Therapeutic Trials (ESCISIT). Ann Rheum Dis
  2003621145-1155.
• 6. Dawson J, Fitzpatrick R, Murray D et al.
  Questionnaire on the perceptions of patients
  about total knee replacement. J Bone Joint Surg
  (Br) 19988063-69.
• 7. Creamer P, Lethbridge-Cejku M, Hochberg MC.
  Factors associated with functional impairment in
  symptomatic knee osteoarthritis. Rheumatology
  200039490-496.
• 8. Walker-Bone K, Javaid K, Arden N et al.
  Regular review Medical management of
  osteoarthritis. BMJ 2000321936-940.
• 9. Recommendations for the medical management of
  osteoarthritis of the hip and knee 2000 update.
  American College of Rheumatology Subcommittee on
  Osteoarthritis Guidelines. Arthritis Rheum
  200043(9)1905-1915.

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References 10-15
10. Guidance on the use of cyclo-oxygenase (COX)
II selective inhibitors, celecoxib, rofecoxib,
meloxicam and etodolac for osteoarthritis and
rheumatoid arthritis. NICE Technology Appraisal
Guidance 27, July 2001. 11. Deal CL, Moskowitz
RW. Nutraceuticals as therapeutic agents in
osteoarthritis. The role of glucosamine,
chondroitin sulfate and collagen hydrolysate.
Rheum Clin N Am 199925379-395 12. Is
glucosamine worth taking for osteoarthritis. Drug
Ther Bull 20024081-83. 13. Chard J, Dieppe P.
Glucosamine for osteoarthritis Magic, hype, or
confusion? It's probably safe-but there's no good
evidence that it works. BMJ 2001322(7300)1439-14
40. 14. Guidance on the selection of prostheses
for primary total hip replacement. NICE
Technology Appraisal Guidance 2, April
2000. 15. Guidance on the use of metal on metal
hip resurfacing arthroplasty. NICE Technology
Appraisal Guidance 44, June 2002.
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Supported by an educational grant from
AC April 06