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A patient-centred approach to osteoarthritis care

Health Secretary John Reid announced in April that he wants

to see patient-centred integrated care for arthritis sufferers

– Dr Steve Longworth looks at what GPs can do

Arthritis affects one in five people in the UK and is the largest single cause of physical disability. Osteoarthritis (OA), the most common form, is associated with a considerable burden of disease and is second only to cardiovascular disease in causing severe disability. Arthritis Care estimates there are 8.5 million people living with OA in the UK1. According to WHO, OA is set to become the fourth highest impact condition in women, and the eighth most important in men in the developed world.

As most patients with OA are managed in primary care GPs have an important opportunity to optimise treatment and the recommendations of the European League Against Rheumatism (EULAR) – see overleaf – form a good starting point.

The relationship between the health care team and the patient is vital, with the patient as an active partner in management. The patient is the expert in their illness; they know their pain and disability better than anyone else and will develop strategies to deal with them. Doctors should listen to their concerns and involve them in treatment decisions.

Management options

Treatment should be a combination of non-pharmacological and pharmacological measures. Indirect evidence suggests non-pharmacological treatments offer additional benefits over and above treatment with NSAIDs and analgesics. It is likely each individual patient will have to try a number of management options before finding the combination that works best for them.

Assessment tools can help to grade the patients' pain and disability. Some that can be easily used in the surgery include rating scales, questionnaires and pain diagrams. Using tools before and after treatment is also useful to determine whether it is effective.

Non-pharmacological strategies

Studies suggest education is about 20 per cent as effective as NSAIDs in reducing pain, and can have a synergistic effect with other treatments. Lifestyle modification has an important role in management. Patient information and self-management strategies can empower patients to take control of their arthritis.

Self-management strategies and access to patient organisations and support groups can improve patients' ability to manage their pain and disability (Arthritis Care offers helplines, self-management courses, booklets and local support groups). More non-pharmacological management options are detailed in box 2.

Rest is a traditional treatment for arthritis, but there is surprisingly little evidence to support it, and a lot of evidence that it is harmful2. A better option is to encourage normal activities and advise patients 'It may be hurting, but it isn't harming'.

Pharmacological strategies

Paracetamol should be used as first-line therapy. It is very safe at prescribed doses and inexpensive. Be sure the patient has tried the full dose of 1gm four times daily.

In those patients with a poor response to paracetamol, NSAIDs should be considered: 60 per cent of patients will respond to any NSAID but some patients respond better to NSAIDs from one chemical group than to those from another, so it is worth ringing the changes if the initial selection is unsuccessful.

Slow- or sustained-release NSAIDs may be useful in some patients to reduce the number of doses

that need to be taken and especially overnight to help morning pain and stiffness. There is no evidence they are safer than ordinary NSAIDs.

NICE guidance recommends Cox-2 selective inhibitors should be considered only in patients who may be at 'high risk' of developing serious gastrointestinal adverse events (see box 3).

The use of topical NSAIDs is controversial with one systematic review suggesting efficacy3 and another authoritative source expressing scepticism4. If they do work, then ketoprofen gel 2.5 per cent appears to be the best. Two recent reviews suggest topical salicylates and topical capsaicin appear to have small positive effects and may be useful adjuncts5,6.

The use of symptomatic slow-acting drugs (SYSADOA) is supported by increasing evidence but further research is required. Given that these agents appear to be well tolerated and show some benefit their use should be considered (see box 5).

Steroid intra-articular injections may be used in the management of patients with OA of the knee.

For a long time they have been thought to provide only good short-term efficacy (two-four weeks) but a recent systematic review states the relief may last four-six months7. They are recommended for acute exacerbations.

There are no good clinical predictors of response – the only way to know if an injection will help is to give it.

Surgery

OA is the main cause of joint replacement surgery. In the UK the rate of elective total hip replacement is increasing. Around 40,000 were carried out by the NHS in 1994/5 and a substantial number by the private sector

Patients should be referred for an orthopaedic evaluation if they are disabled by OA or have pain unrelieved by optimal medical management. Joint replacement can be life transforming.

Newer techniques such as metal-on-metal resurfacing are less invasive, and un-cemented hip replacements may be used in relatively young patients who are expected to easily outlive their prosthesis.

Patients should be made aware of the risks and benefits of surgery.

Steve Longworth is a GP in Leicester with a special interest in musculoskeletal medicine and tutor in primary care rheumatology, University of Bath

1. EULAR recommendations for

management of OA

lTreatment should be tailored to the patient

lThe relationship between the health care team and the patient should be a two-way process

lUsing tools can help to assess the patient's pain and disability

l Patient education has a significant impact on pain management

lTreatment should be a combination of non-pharmacological and pharmacological measures

lParacetamol and NSAIDs should be used as first-line pharmacotherapy

lThere is evidence to support use of some symptomatic slow-acting drugs (SYSADOA) for OA – these include hyaluronic acid and over-the-counter dietary supplements,

such as glucosamine and chondroitin

lSteroid intra-articular injections can be useful in acute exacerbations

lConsider surgery in patients unresponsive to medical management

2. Non-pharmacological

management options

lWeight loss

lExercise to improve aerobic fitness

lQuadriceps strengthening exercises

lFlexibility exercises to maintain range of movement

lHydrotherapy

lAssistive devices (canes and frames)

lAppropriate footwear, insoles

lPacing – break up the daily routine into manageable chunks

lJob/pastimes modification

lAids/appliances – for example tap turners, orthoses, splints

lEnvironmental modification – for example non-slip mats, high chair, stairlift

lReferral – physiotherapy, occupational therapy, podiatry

lTaping the patella medially in OA knee

lMassage

lAcupuncture

3. NICE guidance on the use

of Cox-2 selective NSAIDs

Consider a Cox-2 selective inhibitor only in patients with the following

risk factors:

lAged 65 and over

lPrevious upper GI PUB (perforation, ulcer or bleed)

lConcomitant medication(s) that are known to increase the likelihood of upper GI adverse events (such as corticosteroids, anticoagulants)

lSerious co-morbidity, such as cardiovascular disease, renal or hepatic impairment, diabetes and hypertension

lProlonged use of maximum recommended doses of standard NSAIDs; the use of even a Cox-2 selective agent should be considered carefully in this situation (box 5)

4. GI consequences of prolonged

oral NSAIDs

Oral NSAID >two months

1 in 5 patients Endoscopic ulcer

1 in 70 Symptomatic ulcer

1 in 150 Bleeding ulcer

1 in 1,200 Death from bleeding ulcer

Tramer MR et al. Pain 2000;85:169-1823

5. Symptomatic slow-acting drugs

In joints affected by osteoarthritis, the synovial fluid's capacity to lubricate and to absorb shock is reduced, partly due to a reduction in the size and concentration of hyaluronic acid (hyaluronan) molecules.

Hyaluronan produces a highly viscoelastic solution that is a lubricant at low shear and a shock absorber at high shear.

One approach to the management of knee OA is to inject hyaluronan or derivatives (hylans) into the joint8. Their mode of action is not entirely clear. After injection they stay in the joint cavity for only a few days. They may stimulate endogenous hyaluronan synthesis and/or reduce inflammation.

Several preparations are licensed in the UK. There is no evidence that any one product is superior to the others. They are injected after any knee effusion is drained to dryness. Two of the most widely used products, Synvisc and Hyalgan, produce a small reduction in pain compared with placebo that may last several months.

The limited data available suggests the products are as effective as continuous treatment with oral NSAIDs or intra-articular corticosteroid injections.

Hyalgan is lincensed as a drug – five injections at weekly intervals. Synvisc is licensed as a device – three injections at weekly intervals. They cost about £200 per course.

A meta-analysis of clinical trials with the oral supplements glucosamine and chondroitin in patients with knee osteoarthritis concluded that both of these compounds have an effect on symptoms and that glucosamine also has a structure-modifying effect9. However, the effects of chondroitin on structure need further study.

SYSADOAs can be used at any stage of management but clinical experience suggests they are less effective for severe disease.

Key points

lOA is common and causes a lot of pain and disability

lMost patients are treated in primary care

lEULAR guidelines are realistic

lPartnership with the patient is key

lThere's a lot you can do in 10 minutes

References

1. Arthritis Care. OA Nation. 2004 available at www.arthritiscare.org.uk/OANation

2. Allen C et al. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 2000;3541229-1233

3. Moore R A et al. Quantitative systematic review of topically applied

non-steroidal anti-inflammatory drugs. BMJ 1998; 316: 333-338

4. Anon. Topical NSAIDs for joint disease DTB 1999; 37 (11): 87-88

5. Mason L et al. Systematic review of efficacy of topical rubefacients containing salicylates for the treatment of acute and chronic pain.

BMJ 2004;328:995-998

6. Mason L et al. Systematic review of topical capsaicin for the treatment of chronic pain. BMJ 2004;328:991-994

7. Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ 2004;328:869-872

8. Anon. Hyaluronan or hylans for knee osteoarthritis?

DTB 1999;37(9)71-72

9. Richy F et al. Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis. Arch Int Med 2003; 163;1514-22

Further information

www.arthritiscare.org.uk

www.nelh.nhs.uk/musculoskeletal

www.jointzone.org

A CD of The Ten Minute Management of Osteoarthritis

is available free from Arthritis Care

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