Osteoarthritis Diagnosis and management

An overview of diagnosis and management of Osteoarthritis

1. Rachmat Gunadi Wachjudi
Lahir di Garut, 16-1-1955Lahir di Garut, 16-1-1955
PendidikanPendidikan
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 WA
Pekerjaan:Pekerjaan:
Ka Div Ka Div Reumatologi RS Dr Hasan SadikinReumatologi RS Dr Hasan Sadikin
Organisasi ProfesiOrganisasi Profesi
IDI, IDI, IRA, PAPDI, PEROSI, PERALMUNIIRA, PAPDI, PEROSI, PERALMUNI, APLAR, , APLAR,
IPSIPS

2. Osteoarthritis
A Comprehensive
management

3. The Coming Epidemic of ARTHRITIS. 160[24]. 9-12-2002. Time Magazine.
Arthritis:
the most common is
Osteoarthritis

4. 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.

6. Rheumatic ailments
1%
1%
6%
4%
4%
69%
3%2%
10%
Osteoarthritis
SLE
Rheumatoid Artritis
Gouty Artritis
Sp Arthritis
Systemic Sclerosis
Osteoporosis
Soft Tissue
Rheumatism
others

7. 33,2%
6,8%
1,2%
1,1%
1%
Rheumatic diseases

8. slide 8
Vicious Cycles in Osteoarthritis
(OA)
Imbalance of...
Cytokines
Prostaglandin E
2
Cartilage matrix fragments
Free radicals
Proteolytic enzymes
Protease inhibitors
Proteolytic destruction
of cartilage matrix
Altered mechanical
loading of cartilage and
ligaments
Remodeling of
Bone
osteophytosis,
subchondrial
sclerosis
Phasic synovial
Inflammation &
angiogenesis
Peripheral &
central sensitization
 pain
Impaired mobility:
Reduced exercise,
muscle weakness,
joint laxity
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10. 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

11. 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)

13. 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)

14. 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

15. 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.

16. Hand OA Heberden’s nodes (DIP)
Bouchard’s nodes
(PIP)

17. 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

18. Treatment Principles
•Non-Pharmacologic
–Education
–Physiotherapy
•Exercise program
•Pain relief modalities
–Aids and appliances
•Pharmacologic
–Medical Treatment
•Surgical Treatment
•Complementary and Alternative Medicine

19. 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.

20. Pharmacologic therapy
•Analgesic and anti-inflammatory
•Intra-articular corticosteroids
•Intra-articular hyaluronic acid
•Disease modifying Osteoarthritis Drugs

21. Treatment Considerations
First, 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)

22. Disease modifying Osteoarthritis Drugs
•Nutraceuticals
•Diacerein
•SOD ?
•Hyaluronan ?
•Doxy/Minocyclin

23. Nutraceuticals
•Glucosamine
•Chondroitin
•Glucosamine + Chondroitin ?

24. 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

25. 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)

26. Calcitonin & Estrogen
•memiliki efek proteksi terhadap erosi
permukaan kartilago sendi secara
bermakna.
•DMOAD di masa mendatang ?

28. 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

29. •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.

30. Rose hips

31. 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

32. slide 32
* 3 weeks of rosehip treatment resulted in a significant
reduction in pain when compared to placebo (p<0.014)
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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

33. 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)
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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)

34. 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
%

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Rosehip
*
Placebo
Sub-study analysis of Rein et al. Phytomedicine 11(5): 383-391 (2004)

35. 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.

36. Terimakasih