MEDICAL KNOWLEDGE GAPS IN MODERATE-TO-SEVERE ...img.medscapestatic.com/pi/edu/qrcode/posters/... · Robert McCarthy, PhD, Robin Barnes, BS, Sigrid Trier, MPharm, Grażyna Söderbom,

Robert McCarthy, PhD, Robin Barnes, BS, Sigrid Trier, MPharm, Grażyna Söderbom, PhD, Medscape Education, New York, NY

MEDICAL KNOWLEDGE GAPS IN MODERATE-TO-SEVERE OSTEOARTHRITIS TREATMENT: A CLINICAL PRACTICE ASSESSMENT

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AIMMETHODS

Osteoarthritis (OA) pathogenesis involves inflammatory mechanisms that cause joint tissue degradation and remodelling as well as joint pain.1 Clinical practice guidelines advocate pharmacologic treatment targeting pain relief and improvement of joint function with corticosteroids/NSAIDs2 and lifestyle changes, including weight loss. Supplements, eg, chondroitin, glucosamine, and Traumeel/Zeel, are being used increasingly despite often limited clinical evidence.3

A CPD-certified online Clinical Practice Assessment (CPA) was created to evaluate the current knowledge of orthopedists and rheumatologists on the role of inflammation in OA pathophysiology and key clinical data, current guidelines, and treatment approaches in moderate-to-severe OA.

The CPA consisted of 20 multiple-choice questions on patient case histories (4/20), which were designed to be the most challenging questions for participants; OA pathogenesis (2/20); current guidelines such as American College of Rheumatology (ACR),2 European League Against Rheumatism (EULAR),4 Osteoarthritis Research Society International (OARSI),5 National Institute for Health and Care Excellence (NICE),6 American Academy of Orthopaedic Surgeons (AAOS),7 and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)8 (4/20); clinical trial data9-15 (6/20); and current and future clinical OA management strategies (4/20). Three additional questions collected demographic data on participants. The CPA was provided online to healthcare providers without monetary compensation/charge. Immediately after responding to each question, participants were given the correct answer, along with supporting evidence to facilitate learning. Data from 430 orthopedists and 183 rheumatologists who completed the CPA between April 26, 2016, and September 5, 2016, were analyzed. Participant confidentiality was maintained and responses were de-identified and aggregated prior to analyses.

In summary, this activity was designed in such a way that participants were expected, upon completion, to be able to describe the latest concepts in OA pathophysiology, with a consideration of the role of inflammation in OA and to evaluate clinical data and guidelines recommendations on current treatment approaches in moderate-to-severe OA. The educational gaps identified could then be addressed in future initiatives.

RESULTS

37% of orthopedists and 42% of rheumatologists who participated had been practicing for 20 or more years. Among orthopedists and rheumatologists, 39% indicated approximately 11% to 25% of their patients have knee/hip OA. With respect to OA pathogenesis, only 11% of orthopedists and 22% of rheumatologists correctly chose that high bone-mineral density is associated with an increased OA development risk.

Acknowledgements

The assessment was funded through an independent educational grant from Biologische Heilmittel Heel GmbH

For more information, contact Robert McCarthy, Medscape, NY, USA, [email protected]

References

1. Scanzello CR, 2016. Chemokines and inflammation in osteoarthritis: Insights from patients and animal models. J Orthop Res. 2016. doi: 10.1002/jor.23471. [Epub ahead of print].

2. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012;64:465-474.

3. Sherman AL1, Ojeda-Correal G, Mena J. Use of glucosamine and chondroitin in persons with osteoarthritis. PMR. 2012;4(5 Suppl):S110-S116.

4. Jordan KM. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2003;62:1145-1155.

5. McAlindon, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 22:363-388.

6. National Institute for Health and Care Excellence. Osteoarthritis: care and management. NICE Guideline 177. https://www.nice.org.uk/Guidance/CG177. Accessed March 29, 2017.

7. American Academy of Orthopaedic Surgeons. AAOS releases revised clinical practice guideline for osteoarthritis of the knee [press release].http://newsroom.aaos.org/media-resources/Press-releases/aaos-releases-revised-clinical-practice-guideline-for-osteoarthritis-of-the-knee.htm Accessed March 29, 2017.

8. Bruyere O, Cooper C, Pelletier J-P, et al. An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arth Rheum. 2014;44:253-263.

9. Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Eng J Med. 2006;354:795-808.

10. Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee: a Cochrane systematic review. Br J Sports Med. 2015;49:1554-1557.

11. Guermazi A, Niu J, Hayashi D, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012;345:e5339.

12. Hunter DJ, Beavers DP, Eckstein F et al. The Intensive Diet and Exercise for Arthritis (IDEA) trial: 18-month radiographic and MRI outcomes. Osteo Cart. 2015;23:1090-1098.

13. Larmer PJ et al., 2014. Systematic review of guidelines for the physical management of osteoarthritis. Arch Phys Med Rehabil. 2014;95:375-389.

14. Lozada C, del Rio E, Reitberg DP, et al. A multi-center double-blind, randomized, controlled trial (db-RCT) to evaluate the effectiveness and safety of co-administered Traumeel (Tr14) and Zeel (Ze14) intra-articular (IA) injections versus IA placebo in patients with moderate-to-severe pain associated with OA of the knee. Abstract presented at: 2014 American College of Rheumatology Annual Meeting; November 1-19, 2014; Boston, MA. Abstract 2896.

15. Lozada C et al., 2015. Risk-benefit of co-administered Traumeel® (tr14) and Zeel® (ze14) intra-articular (ia) injections in patients with moderate-to-severe pain associated with OA of the knee (OAK). Abstract presented at: European League Against Rheumatism (EULAR) Congress 2015; June 10-13, 2015; Rome, Italy. Abstract THU0441.

16. Olivotto E, Otero M, Marcu KB, et al. Pathophysiology of osteoarthritis: canonical NF-Kappa B/IKKß-dependent and kinase-independent effects of IKKa in cartilage degradation and chondrocyte differentiation. RMD Open. 2015;1:e000061.

17. Schneider C. Traumeel -- an emerging option to nonsteroidal anti-inflammatory drugs in the management of acute musculoskeletal injuries. Int J Gen Med. 2011;4:225-234.

18. de Meneses S et al., 2016. Osteoarthritis guidelines: Barriers to implementation and solutions. Ann Phys Rehabil Med. 2016;59:170-173.

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CONCLUSION

This educational research on medical knowledge and patient care practices of specialist OA clinicians yielded important insights into clinical gaps in their knowledge, skills, attitude, and competence in the clinical evaluation and treatment of patients with moderate-to-severe OA. Knowledge gaps were identified in 4 areas:

• The role of inflammation in OA pathogenesis

• OA management with pharmacologic therapy and supplements according to guidelines and current clinical evidence

• The bioavailability of different application forms of OA therapies

• The role of other interventions

This assessment also highlighted barriers in the clinical evaluation, diagnosis, and treatment of patients with moderate-to-severe OA, reflected in the recently reported clinical difficulties of OA guideline interpretation.18 There is a need and opportunity for further education of clinicians to improve the clinical management of OA.

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FIGURE 1

FIGURE 2

FIGURE 3

Recent studies have suggested a role for a number of pro-inflammatory transcription factors, kinases, and cytokines in the pathogenesis and progression of OA. Which one of the following markers and mediators of inflammation has been implicated in OA?

Answer ChoicesOrthopedists (n = 430) Rheumatologists (n = 183)

% (n) % (n)

A Nuclear-factor kappa beta 11% (46) 32% (59)

B Elevated levels of interleukin-10 (IL-10) 74% (320) 53% (97)

C Melanocortin 4 receptor activation 1% (6) 8% (14)

D TNF-α depletion 13% (58) 7% (13)

Which one of the following therapeutics is included among the National Institute for Health and Care Excellence (NICE) recommendations for the pharmacological management of knee and hip OA?


% (n) % (n)

A Chondroitin 21% (90) 20% (36)

B Green tea extract 2% (10) 1% (2)

C NSAI-articular (IA) hyaluronic acid 60% (258) 36% (65)

D Topical capsaicin 17% (72) 44% (80)

Recently, ESCEO developed an algorithm for the treatment of knee OA consisting of 4 multimodal steps. Which of the following statements correctly describes one of these steps?


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AIn Step 1, the focus is strictly nonpharmacological, with emphasis upon lifestyle modification, weight loss, diet, and exercise

75% (322) 77% (141)

BIn Step 2, the focus is pharmacological, with the persistently symptomatic Step 1 patient treated with agents (eg, NSAIDS) designed to address pain and inflammation

15% (65) 13% (24)

CIn Step 3, pharmacological treatment is intensified, with IA corticosteroids or hyaluronate for further symptom relief

7% (29) 7% (13)

DIn Step 4, opioids are introduced, both localized, short-term weak opioids, and classical, centrally administered opioids

3% (14) 3% (5)

Only 11% of orthopedists and 32% of rheumatologists were able to identify nuclear-factor kappa-B as an inflammatory marker associated with osteoarthritis.16

Clinicians’ knowledge of current guidelines also varied, as shown in figures 2 and 3.

While almost half of rheumatologists (44%) knew that topical capsaicin was recommended for treatment of knee/hip OA by the NICE guidelines, orthopedists were less familiar with these guidelines.

The majority of orthopedists (60%) stated that NICE had recommended intraarticular hyaluronic acid.

More than one-third of rheumatologists (36%) also stated incorrectly that intraarticular hyaluronic acid was recommended in the NICE guidelines.

The majority of orthopedists (85%) and rheumatologists (87%) were unfamiliar with the recent algorithm developed by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) for the treatment of knee OA .

47% of orthopedists and 43% of rheumatologists correctly answered questions on the IDEA study,12 on the Cochrane Review,13 on pain/exercise programs for knee OA (71% and 70%, respectively), and on the Mozart study14,15 with Traumel/Zeel (43% and 45%, respectively), but fewer were familiar with data on land-based exercises for hip OA.10,11 These results are shown in figures 4 and 5 respectively.

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FIGURE 4

In a population-based observational study, Guermazi et al used MRI findings to assess the prevalence of “any abnormality” and the “most common abnormality” suggestive of knee OA in a population (n=703) aged >50 who had no radiographic evidence of disease. Which of the following statements correctly reports the findings of this study?


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APrevalence of “any abnormality” in this cohort was 89%, with presence of osteophytes the most common abnormality (74%)

15% (64) 14% (26)

BPrevalence of “any abnormality”” was 89%, with the presence of cartilage damage the most common abnormality (83%)

26% (111) 22% (40)

CPrevalence of “any abnormality” was 94% in the subgroup complaining of painful knees, but was much lower (71%) in the subgroup not complaining of painful knees

15% (65) 17% (32)

DPrevalence of “any abnormality” and pain was significantly higher (P =.05) for the subgroup with BMI ≥27.1 kg/m2 compared to the subgroup with lower BMIs (<25 kg/m2)

44% (190) 46% (85)

Very few participants of either speciality were familiar with these findings.11 Only 15% of orthopedists and 14% of rheumatologists answered correctly that the study showed that the prevalence of “any abnormality” in the cohort of patients aged >50 years with knee OA and no radiographic/MRI evidence of disease was 89%, with the presence of osteophytes being the most common abnormality (74%).

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FIGURE 5

A 2014 Cochrane review noted that land-based exercise for treatment of hip osteoarthritis improved physical function and reduced pain. These benefits were sustained for at least how long after the completion of the various exercise programs?


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A 1 to 2 weeks 5% (22) 3% (6)

B 2 to 4 weeks 24% (102) 27% (49)

C 2 to 3 months 41% (176) 32% (59)

D 3 to 6 months 30% (130) 38% (69)

Only approximately one-third of participants (30% of orthopedists and 38% of rheumatologists) were aware that the benefits of land-based exercise for the treatment of hip OA improved function and reduced pain were sustained for 3 to 6 months after completion of the exercise programs; 32% of rheumatologists and 41% of orthopedists opted for 2 to 3 months’ benefit.

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FIGURE 6

ST is a 65-year-old woman with a long-standing history of progressive knee pain, worse in the right knee. Examination reveals no swelling and minimal lateral perimeniscal region tenderness; there is full range of motion of the right knee. Radiographic weight-bearing examination of the bilateral knees reveals only minimal tibiofemoral compartmental narrowing and no patellofemoral compartmental narrowing. There are no osteophytes noted. For this patient, which one of the following treatments has been associated with a reduction in the progression of knee OA?


% (n) % (n)

A Estrogen plus progestin therapy 17% (71) 17% (31)

B Joint lavage 26% (113) 25% (45)

C Vitamin D 40% (171) 46% (84)

D Vitamin C 17% (75) 13% (23)

A case history question was developed on the potential benefit of vitamin C in reducing the progression of knee OA, as shown in Figure 6.

Very few orthopedists (17%) and rheumatologists (13%) were aware that treatment with vitamin C has been associated with the reduction in progression of knee OA, and the majority of both groups instead opted for vitamin D, followed by joint lavage.

With respect to current and future OA treatment options, less than half of the orthopedists (46%) and rheumatologists (44%) were aware of possible differences between intra-articular injection and systemic administration of OA treatments. Twenty-six percent of orthopedists and 36% of rheumatologists knew that bisphosphonates may inhibit osteoclast activity and reduce bone erosion in joints, but only 11% of orthopedists and 15% of rheumatologists stated correctly that the fracture risk with short-acting opioids was greater than with long-acting opioids, especially during treatment initiation (Figure 7).

Regarding supplementary options, 25% of orthopedists and rheumatologists knew that intra-articular Traumel/Zeel was a fixed combination of a large number of botanical and mineral extracts and dilutants, and a potential treatment for acute musculoskeletal injury and chronic pain associated with knee OA.14,15,17

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FIGURE 7

A number of trials and meta-analyses have evaluated opioid analgesia in older adults with OA. Based on the results of those studies, which one of the following observations is correct?


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ARisk of fracture appears to be greater with short-acting opioids vs long-acting opioids particularly during the treatment initiation period

11% (49) 15% (27)

B Addiction risk associated with opioids is potentiated in older adults vs younger cohorts 14% (62) 11% (21)

C Compared with NSAIDs, treatment discontinuation is lower with opioid analgesia 10% (45) 11% (21)

DMeta-analyses data indicate that the most common adverse events associated with opioid therapy are constipation and respiratory depression

64% (274) 62% (114)

The majority of both groups chose correctly that the most common AEs associated with opioid therapy are constipation and respiratory depression; however, few orthopedists (11%) and rheumatologists (15%) were aware that the fracture risk with short-acting opioids was greater than with long-acting opioids, which was the correct answer to the question about specifically targeting older adults with OA.

Documents

MEDICAL KNOWLEDGE GAPS IN MODERATE-TO-SEVERE ...img.medscapestatic.com/pi/edu/qrcode/posters/... · Robert McCarthy, PhD, Robin Barnes, BS, Sigrid Trier, MPharm, Grażyna Söderbom,