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The Management of Osteoarthritis: For Primary Care Physician
The Management of Osteoarthritis: For Primary Care Physician
Women Men
80
60
40
20
0
18–24 25–34 35–44 45–54 55–64 65–74 75–84 85+
Age Group, years
Anatomic
abnormalities Genetic and
metabolic
Microfractures diseases
and bony Abnormal stresses Abnormal cartilage
remodeling Inflammation
Loss of joint
stability Immune
Compromised cartilage system
Trauma activity
Cartilage breakdown
Symptoms
1 Persistent knee pain √
2 Limited morning stiffness √
3 Reduced function √
Signs
4 Joint crepitus √
5 Restricted movement √
6 Bony enlargement √
Numbness ====
Pins and needles °°°°°
° Burning
xxxxxxxx
Stabbing ///////
Rating scales
• Pain intensity
0 No pain
1 Mild
2 Discomforting
3 Distressing
4 Horrible
5 Excruciating
Key principle 4 Patient education
Maintain and
improve joint
mobility
Reduce Reduce
joint pain and physical
stiffness disability
Knee and Hip OA:
Goals of
Treatment
Improve Educate
HRQoL patients
Limit
progression of
joint damage
Surgical
■ Total joint replacement ■ Lavage/debridement in knee OA†
■ Unicompartmental knee replacement ■ Joint fusion after failure of joint
■ Osteotomy and other joint preserving replacement
surgical procedures
24
Please see Full Prescribing Information available at this presentation.
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
-0.5
p=0.05, active treatment vs.
Mean Change in Score
-1.5
-2.0
-2.5
-3.0
placebo (n=200)
-3.5
celecoxib 100 mg BID (n=199)
Cardiovascular
CardiovascularRisk
Risk
NSAIDs
NSAIDsmaymaycause
causeananincreased
increasedrisk
riskof
ofserious
seriouscardiovascular
cardiovascularthrombotic
thrombotic
events,
events,myocardial
myocardialinfarction,
infarction,and
andstroke,
stroke,which
whichcan
canbe
befatal.
fatal.This
Thisrisk
riskmay
may
increase
increasewith
withduration
durationofofuse.
use.Patients
Patientswith
withcardiovascular
cardiovasculardisease
diseaseor orrisk
risk
factors
factorsfor
forcardiovascular
cardiovasculardisease
diseasemay
maybebeat
atgreater
greaterrisk.
risk.
[Product]
[Product]is
iscontraindicated
contraindicatedfor
forthe
thetreatment
treatmentof
ofperioperative
perioperativepain
painin
inthe
the
setting
settingof
ofcoronary
coronaryartery
arterybypass
bypassgraft
graft(CABG)
(CABG)surgery.
surgery.
Gastrointestinal
GastrointestinalRisk
Risk
NSAIDs,
NSAIDs,including
including[product],
[product],cause
causeananincreased
increasedrisk
riskof
ofserious
serious
gastrointestinal
gastrointestinaladverse
adverseevents
eventsincluding
includingbleeding,
bleeding,ulceration,
ulceration,and
and
perforation
perforationof
ofthe
thestomach
stomachor orintestines,
intestines,which
whichcan
canbebefatal.
fatal.These
Theseevents
events
can
canoccur
occuratatany
anytime
timeduring
duringuseuseand
andwithout
withoutwarning
warningsymptoms.
symptoms.Elderly
Elderly
patients
patientsare
areat
atgreater
greaterrisk
riskfor
forserious
seriousgastrointestinal
gastrointestinal(GI)
(GI)events.
events.
APTC Composite End Point (Adjudicated):
Celecoxib vs ns-NSAIDs
Meta-analysis of 25 RCTs
2.0
P =.59 (NS)
Relative Risk (CI) of Serious
1.5
CV Adverse Events
1.0 0.90
1.0 (95% CI: 0.60-1.33)
49 events
54 events
0.5
0
ns-NSAIDs Celecoxib 200-800 mg daily
(n=13,990) (n=19,773)
9
7.7
Systolic blood pressure, mm Hg
8
7
6
5 *
4 3.6
3 2.4 *
2 ++
+
+
1
0
celecoxib 200 mg BID (n=21) naproxen 500 mg BID (n=21) etoricoxib 90 mg OD (n=21)
Compared to naproxen and etoricoxib, celecoxib only shows significant change compared to placebo.
Meanwhile etoricoxib shows significant increase compared to placebo, baseline, and celecoxib and
naproxen.
+ Significantly different from placebo (P ≤ .05)
* Significantly different from baseline (P ≤ .05), placebo (P ≤ .05), and naproxen and celecoxib (P < .03)
Schwartz JI et al. J Clin Pharmacol 2007;47:1521-31.
Coxibs vs. ns-NSAIDs: GI and CV Benefit/Risk Profile
Moore et al. 2007: GI and CV Event Rates
celecoxib
etoricoxib
lumiracoxib
all coxibs
6 5.2
5 4.1
% Patients
4
3
1.7
2 1.1
1
0
CV / renal AE Hepatic AE
1.2
0.97
1 celecoxib
% hepatic events
diclofenac
0.8
0.59 ketoprofen
0.6 0.5 meloxicam
0.37 etodolac
0.4 0.31
0.24 0.21 piroxicam
0.2 ibuprofen
0
A case/noncase analysis of spontaneous reports was conducted to compare the hepatic safety profile of COXIBs and ns-
NSAIDs.
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 1997;259:296-297.
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 2003;62:1145-1155.
6. Dawson J, Fitzpatrick R, Murray D et al. Questionnaire on the perceptions of patients
about total knee replacement. J Bone Joint Surg (Br) 1998;80:63-69.
7. Creamer P, Lethbridge-Cejku M, Hochberg MC. Factors associated with functional
impairment in symptomatic knee osteoarthritis. Rheumatology 2000;39:490-496.
8. Walker-Bone K, Javaid K, Arden N et al. Regular review: Medical management of
osteoarthritis. BMJ 2000;321:936-940.
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 2000;43(9):1905-1915.
References 10-15
46
Please see Full Prescribing Information available at this presentation.