NOTES FOR MED 2 2019 FOR LECTURE ON THE PHARMACOLOGIC TX OF OA

Rhonda Shuckett MD FRCPC (Internal Medicine and Rheumatology) ABIM

(Rheum) rhoshu@telus.net

Lecture Tuesday, Jan 17, 2023

{I have no conflicts of interest}.

!) NON PHARMACOLOGIC WAYS TO TREAT OSTEOARTHRITIS (OA)

A. Education

B. Weight control, even in established OA of knees, it can help

Also remember fat tissue (adipocytes) release: leptins and adiponectins that can
lead to joint damage directly.

C. Physiotherapy / Occupational Therapy

Physio--> Quad strengthening exercises, etc.

For a lower limb OA joint, using a cane in the opposite hand to the

painful knee or hip

D. Bracing, such as a knee unloader brace (eg Generation 2 brace).

E. Emotional support

2) MEDICAL/PHARMACEUTICAL MEANS OF TREATING OA (What are the

contenders a la Marlon Brando?)

A. Oral medications

i) Acetaminophen full dose (if no contraindication) push to 2 grams/d if normal

liver and kidney function. (Recommended by American College of Rheum (ACR))
However metanalysis in the British literature (Lancet/ BMJ) challenge efficacy of
acetaminophen in OA.

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ii) NSAIDs (Non Steroidal Anti Inflammatory Drugs)

Non-selective NSAIDs vs Selective COX-2 inhibitor NSAIDs

What are the pros and what are the con's of NSAIDs ?

PRO's of NSAIDs can help inflammation and pain (even in this "non inflammatory"
form of arthritis.

They are recommended as having a role by ACR

CON's of NSAIDs:

Traditional or non selective NSAIDs: high risk of NSAID gastropathy, especially in

older people aged 55 yrs or more (Hey...that's not so old...sorry I am getting
personal about this!!!). NSAID gastropathy includes Gastro esophageal irritation,
gastritis, bleeding gastric or duodenal ulcers, gastric ulcers can perforate and
bleed and are often asymptomatic before.

THUS...

Clinical TIP:

Gastroprotection: If an older patient...what is the age cut off...quite arbitrary..

needs to be on long term non-selective NSAIDs, use a PPI (Proton Pump Inhibitor)

The Cox -2 selective NSAIDs (Celexicob ) does not affect the upper GI mucosa...it's
main reason for being developed.

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ALL NSAIDS, both non selective and COX-2 selective can:

Affect renal function , especially if patient has high BP, they can increase BP

They can also have some cardiovascular risks

Clinical TIP:

In a patient on chronic NSAIDs, esp if older. follow CBC to r/o low hemoglobin
and check creatinine and probably liver enzymes every few months.

III) OPIATE DRUGS: EG TRAMADOL/TRAMACET versus tylenol #3 or stronger

opiates

Controversy but we need to treat pain. Try tramadol first, but as one of your
fellow students pointed out so well, it is not covered by pharmacare so in a real
world, may reach out to tyl #3 or even something stronger.

Consider for your interest reading Canadian and BC guidelines for Opiates in non
Cancer care.

B. TOPICAL ANTI INFLAMMATORIES/ANALGESICS:

Diclofenac: some efficacy according to the ACR, we often order

compounded 10% diclofenac (volataren).. can be first line

Capsaicin: less evidenced according to ACR. as more for neuropathic

pain.

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C. INJECTABLE TREATMENTS

i) Injectable corticosteroids (Steroid injections: Kenalog or Depomedrol)

( and the pros and cons and controversies) (ACR says yes)

? no more than 3 injections in one joint in a lifetime... do they damage the

cartilage somewhat... they do inhibit IL-1 and those nasty metalloproteases.

or ..no more than 2 to 3 cortisone injections a year, eg for OA knee, especially in

older patient who is not a surgical candidate... the controversy lives on and on.....

ii) Viscosupplementation/ Hyaluronic acid (HA) injections

Efficacy not clear. Not recommended by ACR but often tried in OA knee

About a toss of a coin if these will work in a given pt. Expensive. If you are facing
total knee replacement, it might be worth trying HA injections

D. COMPLEMENTARY AND ALTERNATIVE TX OF OA (CAM):

-Ginger??/ apple cider vinegar/ Diet????? role of acupuncture ?

-Medical marijuana Mainly use of CBD oil which does not have s/es of CBD.

-NUTRACEUTICALS

Glycosamine sulfate (GLS-500) and Chondroitin Sulfate (CS)

Provide GAG substrate. Inhibit IL-1 and matrix metalloproteases (those nasty
enzymes like MMP-1 and 13 (collagenases) and MMP 3 (stromelysin:
proteoglycanase)

But.. do they work??. ACR suggests No Role.

But... they are safe... why not.

Some patients take MSM or Shark Fin Cartilage.. do they work???

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THERAPEUTIC HORIZONS IN OA:

DMOADS: Disease Modifying Anti OA Drugs:

Strontium, Tetracycline have been studied... some efficacy, inhibits neutral

metallo-proteases...but overall not routinely used.

No other DMOADS at present in general use.

OA is far more primitive in our management than is inflammatory arthritis like

Rheumatoid Arthritis... stayed tuned for the latter... in week 62 !!

Cartilage transplants and chondrocytes transplants, plus a bit of growth peptide

and maybe we can resurface the cartilage (at least for an osteochondral defect)

But...remember OA usually involves quite a large area of cartilage loss...

mechanics are at play... how can we change the biomechanical progression of OA.

Also, in OA the Catabolic limb is really up regulated...there have been trials to

introduce TIMPS (Tissue inhibitors of metallo proteases) into the cartilage by
injection.. delivery into the cartilage is a challenge and these have not been taken
any further... but it would be ideal if we could inhibit these villainous enzymes.

OUTCOME METHODS FOR EVALUATING EFFECTS OF OUR TREATMENT OF OA:

Just be aware of the terms --WOMAC and AIMS2 (SF (Shortened form) are tools
we use in Rheumatology in assessing outcome for OA. Do not worry about
anything more on these... just want you to realize we must be rigorous in
measuring outcomes to therapy.

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