WASHINGTON, D.C.—Will we witness dramatic breakthroughs in treating osteoarthritis (OA) in the coming decade? That’s the question three experts sought to address at a presentation titled, “Osteoarthritis Therapeutics: Will This be the Decade for Breakthroughs?” at the 2012 ACR/ARHP Annual Meeting, held here November 9–14. [Editor’s Note: This session was recorded and is available via ACR SessionSelect at www.rheumatology.org.]
Novel treatment strategies for OA aim to relieve symptoms like pain, to rebuild or replenish deteriorated cartilage and bone, or to replace the damaged joint altogether through surgery. Every treatment comes with potential adverse effects, and some lack measurable efficacy, the panelists noted. Most importantly, they stressed that rheumatologists use nonpharmacologic strategies first and that future strategies should slow disease progression through early detection and intervention efforts.
A number of currently available pharmacologic options enable rheumatologists to treat OA pain and other symptoms, said Marc Hochberg, MD, MPH, professor of medicine at the University of Maryland School of Medicine in Baltimore. He stressed to the audience that when treating their OA patients, rheumatologists should first offer guidance on nondrug approaches like exercise and weight reduction, then add layers of drugs as necessary. Treating OA pain effectively often helps patients achieve better physical function and, in turn, achieve better sleep and other positive outcomes, he said.
Acetaminophen is no longer strongly recommended as the first option to treat OA due to its minimal efficacy on pain and lack of efficacy on function and stiffness, Dr. Hochberg noted. Although it is safer for the upper gastrointestinal tract than traditional nonsteroidal antiinflammatory drugs (NSAIDs), there is evidence for liver-related side effects with its long-term use, he said. The U.S. Food and Drug Administration recommends no more than 3,000 milligrams of acetaminophen per day, and rheumatologists should warn OA patients about taking over-the-counter drugs for colds that contain acetaminophen in addition to their regular daily dose for pain, he added.
Effective treatments incurring minimal adverse effects are topical analgesics, including 1% diclofenac gel for pain and 1.5% diclofenac solution for the signs and symptoms of OA, said Dr. Hochberg. The main adverse effect is dry skin at the application site; this is seen less with the gel preparation. Among injectable treatments, intraarticular corticosteroids are efficacious at reducing pain, but viscosupplementation shows mild efficacy at best, he said.
Oral NSAIDS and Other Oral Drugs
Oral NSAIDs cause many adverse events that discourage their use for treating chronic OA pain, especially in patients 75 years and up, Dr. Hochberg said. When used in younger patients, the upper gastrointestinal adverse effects may be attenuated with misoprostol or proton pump inhibitors, Dr. Hochberg said. Although numerous NSAIDs are available, “there is no substantial evidence that one [nonselective] NSAID is more efficacious than another,” he said. He also stressed recent label changes on ibuprofen that state it can interfere with the antiplatelet effect of low-dose aspirin, reducing protection against heart attacks and strokes. “This is something our residents know nothing about,” Dr. Hochberg said.