A 56-year-old woman presents to her

doctor’s office complaining of gradually

progressive, non-painful enlargement of the
terminal joint on her left hand over a 9-month
period. She has some stiffness with typing but
not first thing in the morning. She also reports
pain in her right knee, which occasionally “locks
up.” The right knee also hurts after long walks.
BP- 130/85 mm Hg
HR- 80 bpm
Wt - 285 lb.
 Non- tender enlargement of her left distal
interphalangeal (DIP) joint
 Right knee noted to have crepitus
 Slightly decreased range of motion
 No redness or swelling.
 OBJECTIVES
1. Know the major clinical characteristics of the disease.

2. Be familiar with management approaches to disease.

3. Understand the major classes of medications used for

disease.

4. Know how to differentiate the disease

 PATIENT HISTORY

► 56-year-old obese woman

► complaints of activity related joint disease in the left DIP and right knee.
► no evidence of synovitis on examination

NEXT STEP
Obtain
 erythrocyte
sedimentation rate (ESR)
 plain x-rays of the hand
and knee.
 DIAGNOSIS
OSTEOARTHRITIS

BEST INITIAL TREATMENT

NSAID’s
Acetaminophen.
 MAJOR CLINICAL CHARACTERISTICS
OSTEOARTHRITIS
The most common joint disease in adults.
It is uncommon before age 40, but highly prevalent
over age 60.
The disease affects women more often than men.
Begins insidiously, progresses slowly, and eventually
may lead to disability, recurrent falls, inability to live
independently, and significant morbidity.
 MAJOR CLINICAL CHARACTERISTICS
OSTEOARTHRITIS
 Often experience joint stiffness, which occurs with
activity or after inactivity (“gel phenomena”) and
lasts for less than 15 to 30 minutes.

 In contrast to the morning stiffness of patients with an

inflammatory arthritis, such as rheumatoid arthritis
(RA), which often lasts for 1 to 2 hours and often
requires warming, such as soaking in a hot tub, to
improve.
 MAJOR CLINICAL CHARACTERISTICS
OSTEOARTHRITIS
 Early in the disease, there are no obvious findings.
 There may be some crepitus (creaking sound) in the
joint, and, unlike inflammatory arthritis, there is often
no or minimal tissue swelling (except in the most
advanced disease). Bony prominences, especially in
the DIP/ PIP joints,can occur later.
 MAJOR CLINICAL CHARACTERISTICS
OSTEOARTHRITIS
 Laboratory examination typically is unremarkable;
inflammatory markers such as ESR, C-reactive protein,
and white blood cells (WBCs) all are normal.
 Likewise, autoimmune studies such as antinuclear
antibody (ANA), rheumatoid factor, and complement
levels also are normal.
 If the joint is aspirated, then examination of the
synovial fluid also reflects a lack of inflammation:
WBCs less than 2000/ mm3,
protein less than 45 mg/ dL without crystals, and
glucose equal to serum.
 MAJOR CLINICAL CHARACTERISTICS
OSTEOARTHRITIS
 X-ray evaluation in OA may show osteophytes that
are the most specific finding in the disease but might
not be found early.
Other characteristics seen on x-rays include
joint space narrowing, subchondral sclerosis, and
subchondral cysts.
 MAJOR CLINICAL CHARACTERISTICS
OSTEOARTHRITIS
 It is critical to differentiate OA from other conditions
that may present similarly.

 Periarticular pain that is not reproduced with

passive motion suggests bursitis or tendonitis.
 MAJOR CLINICAL CHARACTERISTICS
OSTEOARTHRITIS
 Prolonged pain lasting for more than 1 hour points
toward an inflammatory arthritis.
 Intense inflammation suggests one of the
microcrystalline diseases (gout/ pseudogout) or
infectious arthritis.
 MAJOR CLINICAL CHARACTERISTICS
OSTEOARTHRITIS
 Systemic constitutional symptoms, such as weight loss,
fatigue, fever, anorexia, and malaise, indicate an
underlying inflammatory condition, such as
polymyalgia rheumatica, rheumatoid arthritis,
systemic lupus erythematosus (SLE), or a malignancy,
and generally demand aggressive evaluation.
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 Education is critical.
Encourage the patient to stay active, because not using
the joint can cause further immobility.
Multiple short periods of rest throughout the day are
better than one large period.

 In patients with OA who are overweight, weight loss

of even modest degree may produce improvement in
lower extremity joint pain and function. Other
methods of unloading an osteoarthritic joint include
canes and walkers, which can reduce joint forces at the
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 Other methods of unloading an osteoarthritic joint
include canes and walkers, which can reduce joint
forces at the hip by as much as 50%.
Equipment such as canes and/ or walk
are helpful for patients with advanced disease because
these patients are less stable and, as a result, have
frequent falls.
 Physical therapy in the form of heat applied to the
affected joints in early disease often is helpful.
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 Perhaps the most important intervention is having the
patient maintain full/ near-full range of motion with
regular exercise.

Physical therapy and exercise improve functional outcome and

pain in OA by improving flexibility and by strengthening muscles
that support the affected joints. Moist superficial heat can raise the
threshold for pain, produce analgesia by acting on free nerve
endings, and decrease muscle spasm.
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 Pharmacotherapy early in the course of the disease
consists primarily of acetaminophen, the first line of
therapy.
Acetaminophen can be used on an as needed basis, or
on a schedule for patients with persistent symptoms.
Regular dosing of up to 3 g/ d (eg, 1000 mg every 6 hours
while awake) is considered safe.
Patients using this dosing should be cautioned about
concurrent heavy alcohol use, which may produce
higher risk of hepatotoxicity.
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 Those taking chronic daily acetaminophen, or with any
underlying liver disease, should have periodic
laboratory monitoring for hepatotoxicity.

A large meta-analysis published in the Lancet in 2016 suggested that acetaminophen

was ineffective in treating the pain of OA, and that NSAIDs should be considered first
line.
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 For patients with an inadequate response to
acetaminophen, or with more severe pain can be
advised to try a nonselective nonsteroidal anti-
inflammatory drug (NSAID) or a cyclooxygenase 2
(COX-2) selective NSAID (commonly termed a
“coxib”), which offer higher efficacy for pain relief.
NSAIDs have a higher risk of gastrointestinal irritation and
bleeding, and both NSAIDs and COX-2 inhibitors are
associated with increased risk of adverse cardiovascular
effects.
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
Because of the risks, if NSAIDs or COX-2 inhibitors are
used, they should be used in the lowest dose necessary
and for the shortest period in order to achieve symptom
control.
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 Topical medications such as diclofenac, lidocaine, or
capsaicin may be considered in patients who cannot
tolerate oral NSAIDs or for those at higher risk for
adverse effects (eg, patients over 75 years or those
with significant cardiovascular disease).
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 Intra-articular steroids may be rarely useful for long-
term treatment and can be helpful for the rare
inflammation of a loose cartilage fragment, which may
cause the joint to “lock up.”
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 Surgery is reserved for only the most severe cases,
which include patients who have major instability, a
loose body in the joint, intractable pain of advanced
disease, or severe functional limitation.
 MANAGEMENT APPROACHES
OSTEOARTHRITIS
 Arthroscopic debridement is widely used for those
with symptomatic OA of the knee, especially with a
meniscal tear, but clinical benefit is not supported by
randomized clinical trials. Total joint arthroplasty (eg,
knee replacement) is recommended for patients with
severe symptomatic OA, who fail to respond to
optimal nonpharmacologic and medical therapy, and
for whom OA causes significant impairment in quality
of life.
MANAGEMENT APPROACHES
OSTEOARTHRITIS
THANK
YOU!