02Comprehensive Management of OA Utk Family Physician

Sumartini Dewi Rheumatology division, Internal Medicine Department Faculty of Medicine-UNPAD, Bandung

1995 2006 2006 2010 2010 2012

Medical Doctor, UNPAD Internist, UNPAD Magister of Health, UNPAD Rheumatologist, UI Course on Clinical Epidemiology of Rheumatology (Univ. of Aberdeen, Scotland, United Kingdom). Clinical Certified of Densitometrist (ISCD-PEROSI)

RIWAYAT PEKERJAAN 2006 – SEKARANG :

STAFF. DIVISI REUMATOLOGI DEPARTEMEN ILMU PENYAKIT DALAM FK-UNPAD-RS HASAN SADIKIN BANDUNG

ORGANISASI Anggota IDI, PAPDI, IRA, APLAR, EULAR, IPS, PEROSI •

Comprehensive Management of Osteoarthritis

The most prevalent of Rheumatic Diseases

69% 13%



Osteoarthritis



SLE Rheum arthritis Gouty arthritis Soft tissue Rheum Systemic sclerosis Spondyloarthritis

 

6% 1% 3%

7%

 

1%



23/06/2013

JOINTS OA

S. Dewi Reumatologi Bandung

Rheumatology & Pain update 2013

OSTEOARTHRITIS

OSTEOARTHRITIS

Goals of treatment of OA • • • • • •

Reduction of joint pain and stiffness Maintain and improve joint mobility Reduce physical disability and handicap Improve health-related quality of life Limit the progression of joint damage Educate patients about the nature of the disorder and its management

•

Osteoarthritis and Cartilage, OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence based, expert consensus guidelines, Feb 2008

8

Comprehensive Management of OA What Is The Guidelines?

Clinical practice guidelines • 3 main types of evidence to guide clinical decision-making : 1. Research evidence 2. Expert opinion/experience 3. Patient opinion/acceptability. • All three are equally weighted to ‘best practice’ Lim AYM , Doherty M. International Journal of Rheumatic Diseases 2011; 14: 136–144

The three types of evidence to consider for evidence based management

Research

Best Practice

Expert opinion

Patient opinion Lim AYM , Doherty M. International Journal of Rheumatic Diseases 2011; 14: 136–144

Rheumatic Pain Management • Education Non• Exercise Pharmacologic • Physiotheraphy

• Symptoms aleviation • Structure modification Pharmacologic • Disease modification

American College of Rheumatology 2000 Guidelines for OA of the Knee Nonpharmacologic Modalities

Pharmacologic Modalities : 1st Acetaminophen At increased risk for an upper GI adverse event Viscosupplements COX-2–specific inhibitor Low-dose NSAID and GIprotective agent Glucocorticoid injection

Not at risk for an upper GI adverse event Viscosupplements COX-2–specific inhibitor Low-dose NSAID Glucocorticoid injection

Surgery

ALL OA GUIDELINES AGREE ON : 1. Full holistic patient assessment and individualizing the management plan 2. The use of both non-pharmacological treatments and adjunctive pharmacological treatments 3. Patient information, advice on weight loss if overweight/obese, and a prescription of exercise (both local strengthening and general aerobic fitness – for large joint OA); Lim AYM , Doherty M. International Journal of Rheumatic Diseases 2011; 14: 136–144

ALL OA GUIDELINES AGREE ON : 4. Consideration of paracetamol as first-line oral analgesic, based on relative safety compared to other oral analgetics 5. Many also giving support for topical NSAID 6. Use of intra-articular corticosteroid for marked pain resistant to other measures 7. Consideration of surgery (knee OA, hip OA, thumbbase) for marked pain and disability that interferes with quality of life and which is resistant to other conservative measures. Lim AYM , Doherty M. International Journal of Rheumatic Diseases 2011; 14: 136–144

Key principles1: EULAR guidelines 1. Treatment should be tailored to the patient 2. The relationship between the healthcare team and the patient should be a two-way process 3. Using tools can help to assess the patient’s pain and disability 4. Patient education has a significant impact on pain management 5. Treatment should be a combination of nonpharmacological and pharmacological measures 1.Jordan KM, Arden NK, Doherty M et al. Ann Rheum Dis 2003;62:1145-1155.

Management options1: EULAR guidelines 6. Non-pharmacological management strategies should be incorporated 7. Paracetamol and NSAIDs should be used as first-line pharmacotherapy 8. There is evidence to support the use of some symptomatic slow-acting drugs for OA (SYSADOA) 9. Corticosteroid intra-articular injections can be useful in acute exacerbations 10.Consider surgery in patients unresponsive to medical management 1.Jordan KM, Arden NK, Doherty M et al. Ann Rheum Dis 2003;62:1145-1155.

Figure 2 Summary of NICE recommendations.

Osteoarthritis. Care and management in adults Issued: February 2014NICE clinical guideline 177.guidance.nice.org.uk/cg177 .

2013 OARSI Guidelines for the Non-surgical Management of Knee OA (Recommendation) 1. Accupunture : Uncertain 2. Balnotherapy/Spa Therapy : Appropriate (multiple joint + relevant comorbidities), Uncertain (without relevan comorbid), Uncertain (knee only) 3. Biomechanical interventio : Appropriate 4. Cane : Appropriate (knee only), Uncertain (multiple joint) 5. Crutches : Uncertain

2013 OARSI Guidelines for the Non-surgical Management of Knee OA (Recommendation) 6. Electrotherapy/neuromuscular electric stimulation (Not Appropriate) 7. Exercise land-based (Appropriate) 8. Exercise water-based (Appropriate) 9. Strength training (Appropriate) 10.Self-management and education (Appropriate)

2013 OARSI Guidelines for the Non-surgical Management of Knee OA (Recommendation) 11.Transcutaneous electric nerve stimulation – TENS, knee-only (Uncertain), multiple-joint (Not appropiate) 12.Weight management (Appropriate) 13.Ultrasound . Knee-only (Uncertain), Multiple-joint (Not appropriate) 14.Avocado soybeans (Uncertain) 15.Capsaicin. Knee-only w/o comorbid (Appropriate), Multiple-joint w/relevant comorbid(Not appropriate)

2013 OARSI Guidelines for the Non-surgical Management of Knee OA (Recommendation) 16.Acetaminophen. W/O relevant comorbid (Appropriate), W/ relevant comorbid (Uncertain) 17.Corticosteroid Intra-articular injection (Appropriate) 18.Chondroitin for symptom relief (Uncertain), for disease modification (Not Appropriate) 19.Diacerein (Uncertain) 20.Duloxetine w/o comorbid (Appropriate), w/ multiple joint + relevant comorbid(Appropriate), knee-only w/ relevant comorbid (Uncertain)

2013 OARSI Guidelines for the Non-surgical Management of Knee OA (Recommendation) 21.Glucosamine. For symptom relief (Uncertain), For disease modification (Not appropriate) 22.Hyaluronic acid. Knee-only (uncertain), Multiple-joint (Not appropriate) 23.NSAID oral non selective . W/o comorbid (Appropriate), w/ moderate comorbid risk (Uncertain), w/ high comorbid risk (Not appropriate) 24.NSAID oral Cox-2 inhibitors. W/o comorbid (Appropriate), multiple-joint w/ moderate comorbid risk (Appropriate), Knee-only w/ moderate comorbid (Uncertain), w/ high comorbid risk (Not appropriate)

2013 OARSI Guidelines for the Non-surgical Management of Knee OA (Recommendation)

25.NSAID topical, w/knee-only (Appropriate), Multiple-joint (Uncertain) 26.Opioids transdermal, (uncertain) 27. Opioids oral, (uncertain) 28.Residronate (Not Appropriate) 29.Rosehip (uncertain)

“Uncertain” recommendation is NOT a negative recommendation,

“Uncertain” treatments should be weighed by physicians and patients for merit in specific individual circumstances

An algorithm recommendation for the management of knee OA in Europe and internationally : A report form task force of ESCEO (2014)

An algorithm recommendation for the management of knee OA in Europe and internationally : A report form task force of ESCEO (2014)

Non Pharmacologic management

RISK FACTORS FOR OSTEOARTHRITIS

Figure 2 Obesity and OA: a vicious cycle

Wluka, A. E. et al. (2012) Tackling obesity in knee osteoarthritis Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2012.224

Quadriceps strengthening exercise

Pharmacologic therapy

• Systemic drugs • Topical applications • Intra-articular injections

48

Pharmacologic recommendations for the initial management of knee OA (ACR 2012) We conditionally recommend that patients with knee OA should use one of the following: • Acetaminophen • Oral NSAIDs • Topical NSAIDs • Tramadol • Intraarticular corticosteroid injections

Pharmacologic recommendations for the initial management of knee OA (ACR 2012) We conditionally recommend that patients with knee OA should not use the following: • Chondroitin sulfate • Glucosamine • Topical capsaicin We have no recommendations regarding the use of intraarticular hyaluronates, duloxetine, and opioid analgesics

Step 2 : Advanced Pharmacological Treatment

1. Oral NSAIDs 2. Intraarticular Hyaluronic acid 3. Intraarticular Corticosteroid

Suggested medication dosages and side effects

Suggested medication dosages and side effects

2. Hyaluronic acid • Beneficial effects on • pain, function and pts. global assessment1 • High effect size of 0.632 • Mechanism occurs in 2 • stages, a mechanical & pharmacological stage3 • Not a rapidly acting agent, effect on pain and function up to 6 months4

Non-inferiority to symptomatic efficacy between the HA preparations of various molecular weights (MWs) ESCEO: knee OA pts w/ mildmoderate disease, and severe pts who contraindicated to TKR surgery or wishing to delay

1.Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G.Cochrane Database Syst Rev. 2006(2):CD005321. 2.Bannuru RR, Natov NS, Dasi UR, Schmid CH, McAlindon TE. Osteoarthritis Cartilage. 2011;19(6):611-9. 3.Bannuru RR, Natov NS, Obadan IE, Price LL, Schmid CH, McAlindon TE.Arthritis Rheum. 2009;61(12):1704-11. 4.Miller LE, Block JE. Clin Med Insights Arthritis Musculoskelet Disord.2013;6:57-63.

3. Intra-articular corticosteroids • Patients especially with an • Higher efficacy than IA effusion1 hyaluronicacid over the first weeks after • Joint aspiration of the administration2 synovial fluid followed by IA • But their effect on pain corticosteroids, e.g.metyl may actually last for prednisolone acetate or only a few(1–3) weeks3 triamcinolone 1 hexacetonide 1.Bruyere O, Cooper C, Pelletier JP, Branco J, Brandi ML, Guillemin F, et al. Semin Arthritis Rheum.2014;44(3):253-63 2.Bannuru RR, Natov NS, Obadan IE, Price LL, Schmid CH, McAlindon TE.Arthritis Rheum. 2009;61(12):1704-11 3.Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G.Cochrane Database Syst Rev. 2006(2):CD005321

Step 3: Last pharmacological treatment • Conventional opioid analgesics may cause respiratory depression, dependence and have the potential for drug abuse. • Weak opioids such as tramadol offer good analgesia with improved safety profile • Antidepressants (incl. duloxetine) used in chronic pain syndromes, act centrally to alter pain neurotransmitters (serotonin and norepinephrine) • Tramadol and duloxetine should not be used in combination, due to the overlapping mechanisms of action on central pain neurotransmitters.

Conclusion • In clinical practice, treatment should be based upon the individualized assessment of the patient, taking into account patients’ needs and preferences, or the subjective interpretation of the evidence by the physician. • In the future, identification of patient profiles may lead to more personalized healthcare, with more targeted treatment for OA

REKOMENDASI Perhimpunan Reumatologi Indonesia ( IRA ) untuk Diagnosis dan Pengelolaan Osteoartritis

REKOMENDASI Perhimpunan Reumatologi Indonesia ( IRA ) untuk Diagnosis dan Pengelolaan Osteoartritis

Any questions ? ? ?

74

THANK YOU.....