Osteoarthritis: Managing without surgery

,

Applied Evidence

Osteoarthritis: Managing without surgery

J Fam Pract. 2009 July;58(7):354-361

By

James Crosby, MD

To help patients who want to “try everything” before considering joint replacement, turn to the STEPs approach.

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References

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7. Rozendaal RM, Koes BW, von Osch GJ, et al. Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial. Ann Intern Med. 2008;148:268-277.

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Strength of recommendation (SOR)

Good-quality patient-oriented evidence
Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented evidence, case series

STEPS key: Tolerability/Simplicity: low=less tolerable/more complex; high=more tolerable/less complex.

Osteoarthritis (OA) is a common, almost expected, part of getting old. Some patients require no treatment or have symptoms that are easily controlled with over-the-counter analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) and lifestyle modifications. Others are so debilitated that surgery is the only way to go.

Where does that leave elderly patients in between—those who don’t make good surgical candidates or find little relief from basic interventions and want to “try everything” before surgery?

The best way to answer this question is to utilize the STEPS (Safety, Tolerability, Efficacy, Price, and Simplicity) format, a helpful mnemonic for an objective way to evaluate drugs or medical therapies.¹

The recommendations, strength of recommendation (SOR) ratings, and summaries that follow are presented in this format, and draw upon recent reviews, focused studies, and scholarly analysis provided by the Osteoarthritis Research Society International (OARSI). The interventions are divided into 3 categories:

over-the-counter remedies
nonpharmacologic interventions
injections/prescription drugs.

Over-the-counter remedies

Capsaicin ointment

Recommended (SOR: A).

Safety: High.

Tolerability: Medium. About 50% of patients experience a local (and possibly intense) burning sensation initially, but it generally wanes after several weeks. The number needed to harm (NNH) is about 10 for withdrawal due to adverse effects.²

Efficacy: Medium. Evidence regarding topical capsaicin comes mostly from studies of patients with musculoskeletal conditions in general, not OA specifically. About 40% of patients treated with capsaicin report a 50% decrease in musculoskeletal pain, as do 25% of those using a placebo (number needed to treat [NNT]=8).²

Price: Low. About $15 per month per joint.

Simplicity: Medium. Patients need to apply the ointment 3 or 4 times a day.

Tips: Advise patients to start with the lower strength ointment (it’s available in strengths of 0.025% and 0.075%) and to apply very small amounts initially. Warn them that they may experience a burning sensation; if so, suggest they try cutting down on the recommended frequency.

Tell patients, too, to use topical capsaicin for a few weeks before evaluating its effectiveness or deciding whether to abandon it. Emphasize that it should be used for base pain rather than for acute pain relief. (For those who can’t tolerate capsaicin, topical salicylate may offer similar benefits.)

Glucosamine

Recommended with or without chondroitin (SOR: B).

Safety: High.

Tolerability: High. Side effects are rare.

Efficacy: Low. There have been numerous trials of glucosamine alone (chondroitin alone is not recommended), mostly limited to knee pain. While many have found that glucosamine offers little or no clinical benefit, some have shown a benefit comparable to or slightly better than acetaminophen. Overall, evidence suggests that up to 40% of those who take glucosamine achieve a clinically significant response,^3-5 although the placebo response may be substantial.

FAST TRACK

Chrondroitin alone is not recommended for osteoarthritis, but 1 study found that glucosamine was effective only when combined with chondroitin.

One study found that glucosamine was effective only when it was combined with chondroitin, and only when pain was more than mild.⁶ Another showed no clinical benefit for hip OA.⁷ There is limited evidence for or against the use of glucosamine and chondroitin to slow disease progression; the 2 agents are not recommended for this purpose.

Price: Low to medium ($5-$35 per month).

Simplicity: Medium to high; patients should take glucosamine (or glucosamine and chondroitin) 3 times a day. Compliance is likely to be variable, depending on results.

Tips: Recommend a 4-month trial for most patients, particularly in view of the placebo effect; suggest that patients try a low-priced product and a daily dose of 1500 mg glucosamine, with or without 1200 mg chondroitin. Be sure to tell patients to purchase glucosamine sulfate, not glucosamine hydrochloride.

Evaluate after 4 months, and advise patients to discontinue if there is no significant improvement. Tell them, too, that while preparations vary by manufacturer and price, the difference between the various products is too small to justify the cost of the higher-priced brands.

Nonpharmacologic interventions

Acupuncture

Not recommended (SOR: A).

Safety: High.

Tolerability: Medium to high. Discomfort from the needles varies from slight to none.

Efficacy: Zero to low. Several studies have indicated some beneficial effect, but the degree of improvement has been small, with a sizable placebo effect.⁸ Studies typically include weekly sessions over the course of several months, and have demonstrated up to a 20% improvement in pain and function; however, much of that improvement has been attributed to the placebo effect, as demonstrated by studies that compared acupuncture with a sham procedure.⁸ Most data on acupuncture involve the knee; there is insufficient information about the procedure’s efficacy for other sites and for shorter treatment periods.