Pharmacologic treatment

A variety of pharmacologic treatments are currently available for OA, including, but not limited to, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), topical creams, tramadol hydrochloride, and opiates.15 Acetaminophen tends to be preferred to NSAIDs for arthritic symptoms, especially in older patients, because it has a lower incidence of cardiovascular and gastrointestinal events and is inexpensive, safe, and effective for those with mild arthritic symptoms.15 The current recommendation for patients taking acetaminophen is not to exceed a dosage of 4 g/d in order to avoid hepatotoxicity.16 The Food and Drug Administration (FDA) currently recommends that the quantity of acetaminophen in combination drugs not exceed 325 mg per tablet because of the risk for hepatotoxicity.17

For patients with moderate to severe OA, acetaminophen is often ineffective; therefore, NSAIDs (eg, aspirin, ibuprofen, naproxen, diclofenac, meloxicam, celecoxib) are often prescribed.15 While taking NSAIDs, patients should be educated about the potential risks, including stomach upset, gastrointestinal bleeding, renal dysfunction, and hypertension.15 In patients with a known history of gastrointestinal bleeding, ulcers, renal failure, or poorly controlled hypertension, NSAIDs are not an appropriate treatment option; other medications, such as topical creams and non-opiate or opiate analgesics, may be considered.15

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Topical NSAIDs, such as Voltaren Gel 1% (diclofenac sodium topical gel), have been shown to be effective in treating arthritic pain and cause fewer adverse effects than do oral NSAIDS.18 Voltaren Gel 1%, in particular, has been approved by the FDA for the treatment of OA; the currently recommended dosage is 4 g applied to the affected joint four times per day.19 Topical treatments that may be purchased over the counter include capsaicin, Aspercreme, and Salonpas. Although all medications have known side effects, the topical treatments seem to have less effect on comorbidities, are nonsedating, and are not addictive, yet still provide adequate pain relief.

Another treatment option that may be considered for arthritic pain is the prescription drug tramadol hydrochloride. Tramadol hydrochloride is a mild opioid agonist currently recommended for treating moderate to severe pain when other pharmacologic measures are not an option or have failed; it has not been linked to gastrointestinal, renal, or cardiovascular complications.20

The literature suggests that tramadol hydrochloride is effective for decreasing pain and improving function in patients with OA.21 The currently recommended dosage is 50 to 100 mg by mouth every 4 to 6 hours as needed for pain (not to exceed 400 mg/d; not to exceed 300 mg/d in persons aged 65 years or older).22 Therefore, when other pharmacologic treatments are not available, tramadol hydrochloride may be considered.

When all other pharmacologic measures have been tried and have failed, or when other treatment options are not feasible, opiates or opioids may be considered, but they are not without risk. Opioid analgesics put patients at increased risk for dependency, falls, and fractures, especially older patients. A recent study determined that even the short-term use of narcotics for pain secondary to OA is likely to lead to other forms of morbidity and mortality.23 Therefore, before considering opiates for arthritic pain, clinicians need to take all risk factors into consideration because opiates may ultimately do the patient more harm than good.

Glucosamine and chondroitin

Glucosamine and chondroitin are very popular herbal supplements used in treating arthritis. Glucosamine is a natural substance found in healthy cartilage, primarily in the fluid surrounding the joints. It may be produced in a laboratory or harvested from the shells of shellfish.24 As a dietary supplement, it is believed to have anti-inflammatory properties and assist in cartilage regeneration. Chondroitin is made by the body naturally and helps to retain water in cartilage.24 It too can be made in the laboratory and can also be obtained from the cartilage of other animals, such as pigs, cows, and sharks.24

In many European countries, chondroitin is used as a prescriptive treatment for OA. However, in the United States, it is sold over the counter as a supplement, often in combination with glucosamine. Currently, the AAOS does not recommend glucosamine and chondroitin for the treatment of OA. A review of numerous studies found essentially no evidence that glucosamine and chondroitin, evaluated either alone or in combination, achieves a minimum of clinically important outcomes compared with placebo.25

Chondroitin and glucosamine supplements alone or in combination may not work for everyone with OA. However, patients who take these supplements and who have experienced relief with them should not stop taking them. Both supplements are safe to take on a long-term basis.

Braces and orthotics

Braces and orthotics are often considered for the treatment of OA, but their efficacy may be limited to specific conditions, such as unicompartmental knee arthritis or arthritis of the foot and ankle. To treat OA, universal soft goods, such as wrist splints, neoprene knee sleeves, knee immobilizers, slings, ankle supports, and other devices, are often used to rest and stabilize a joint for several days to relieve pain or to provide compression and “preload” a muscle. Fitting patients adequately with structural braces is often difficult; therefore, custom braces may be used. In particular, for a patient with unicompartmental knee arthritis, a custom brace is helpful in transferring weight from one compartment to the other, relieving pain by approximately 50%.26 However, the AAOS indicates that the evidence for unloader braces is inconclusive and has issued only a moderate recommendation for lateral shoe wedges in treating OA of the knee.25

Orthotic devices are also often recommended for support, alignment, and the prevention or correction of foot deformities.27 Midfoot arthritis and forefoot arthritis are common conditions affecting many individuals. According to Verhoeven and Vandeputte,28 orthotic devices serve as the mainstay of conservative treatment for these conditions because they evenly distribute load across the foot. According to the AAOS,29 an assistive device such as an ankle–foot orthosis may improve mobility, and wearing shoe inserts (orthotics) or custom-made shoes with stiff soles and rocker bottoms can help minimize pressure on the foot and decrease pain. In addition, if a deformity is present, a shoe insert may tilt the foot or ankle back straight, relieving pain in the joint.29 Numerous patients begin by using over-the-counter orthotics, but many eventually benefit from custom-molded orthotics because they often provide greater support and routinely have specific modifications based on the condition being treated.30 The one caveat regarding custom orthotic devices is insurance coverage because they tend to be expensive. However, if a patient has a comorbidity, such as diabetes mellitus, that could exacerbate the foot or ankle condition, plans such as Medicare Part B will generally cover therapeutic shoes and/or inserts annually if the patient meets specific criteria.31

Intra-articular injections

Injections are often the mainstay of conservative treatment for OA because they have demonstrated the ability to provide quick and adequate pain relief. Several different types of intra-articular injections are offered, but the two most commonly used are corticosteroid and hyaluronic acid injections. Corticosteroid injections are currently the only injections approved for essentially every joint. Just as with all other treatment options, results will vary for each patient. A number of patients obtain minimal relief, whereas others experience substantial relief often lasting for several months or even years.

In general, when a corticosteroid is administered, it is often mixed with a local anesthetic, thus providing relief even before the patient leaves the office. However, it may take 24 to 48 hours for the cortisone itself to take effect. Although corticosteroids have proved effective for many patients, they must be used with caution in those with diabetes because they can increase the blood sugar level and cause hyperglycemia. Despite the potential for side effects, as with any other medication, if corticosteroid injections are effective for the patient, they may be repeated safely every 3 to 4 months as needed for pain relief.

Intra-articular injections of the knee joint with hyaluronic acid (viscosupplementation) are currently used by many providers, although they are no longer recommended by the AAOS. Hyaluronic acid is a natural substance in synovial fluid, and its concentration is decreased in the joints of patients with OA.32 In the past, 3 to 5 injections were given sequentially, but treatment is currently available as one injection. Some of the formulations include Synvisc-One, Euflexxa, and Orthovisc.

Intra-articular injections are thought to enhance the viscosity of the synovial fluid by increasing its molecular weight and decreasing the amount of inflammatory cytokines and free radicals to reduce arthritic pain, although the exact mechanism is unknown.19 Unfortunately, hyaluronic acid injections do not provide instant analgesic effects, and often several weeks must pass before any benefit is noticed; however, if the injections are effective, the benefits may last for several months.32 The AAOS currently strongly recommends against using hyaluronic acid because it has been shown to be ineffective.25 Although most studies have failed to show superiority of hyaluronic acid injections to placebo, they may be warranted in patients who are not operative candidates or who are averse to surgical treatment.32 The injections are most commonly used for mild to moderate OA when other conservative treatment options have failed, but they may be worth discussing with patients before surgical measures are implemented.

Conclusion

Clinicians, particularly in the primary care setting, should have an understanding of the available options for the safe, adequate treatment of patients with OA. When formulating a treatment plan and before administering treatment, the clinician must consider all relevant factors, including the severity of the condition as well as the patient’s comorbidities, financial status, and insurance coverage because each of these variables determines what treatment can be prescribed or recommended. It is also important that clinicians understand that a treatment option that is beneficial for one patient may be ineffective for another. The goals of the treatment of OA are to relieve pain, improve mobility, and maintain or restore quality of life. If or when nonoperative interventions appear to fail to achieve these stated goals, the clinician may consider referral to an appropriate musculoskeletal specialist for surgical evaluation.

Tasha Lee, DNP, FNP-BC, ONP-C, is a certified family nurse practitioner at Coastal Orthopedics in Conway, S.C.

References

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All electronic documents accessed April 5, 2016.

From the June 01, 2016 Issue of Clinical Advisor

Topics:

Arthritis Orthopedics Osteoarthritis Pain Management