Oa pharmacotherapy

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  • 1. Goals of Drug Treatment Rapid relief of pain Slow relief of symptoms Slowing down the progression

2. Drugs Used For OA Paracetamol NSAIDs Tramadol Steroid injections Topical Capsaicin Viscosupplementation Neutraceuticals 3. Paracetamol in OA Dose 2-4,000 mg daily May be used in doses up to 2,600 mg/d continuously for 2 yrs with good safety More effective than placebo, less than NSAIDs Effect size 0.21 is small but significant 4. NICE Guidelines 5. RFs for NSAID-induced Ulcers Age >60 yrs Past history of peptic ulcer PH of adverse events with NSAIDs Concomitant steroid use High dose or multiple NSAIDs Individual NSAIDs High: piroxicam, ketoprofen Low: Ibuprofen 6. Strand V et al. J Rheum 2011 7. NSAIDs: Take Home NSAIDs are superior to placebo & paracetamol Pooled effect size 0.32 Has substantial AEs Continuous use (particularly celecoxib) offers better pain relief, function & QoL, with fewer side effects Most NSAIDs increase vascular events: Diclofenac, indomethacin, meloxicam Ibuprofen reduces efficacy of aspirin Naproxen neither increases nor decreases 8. IA Steroid 9. IA Steroid: Take Home Effect size 0.6, but short-lived More effective in patients with effusion 3 monthly use over 2 yrs found to be safe and effective in Raynaulds study 10. Viscosupplementation 11. Viscosupplementation: Take Home Effect size small Administration cumbersome Local AEs common Should not be routinely used 12. Tested Molecules Neutraceuticals Diacerin Doxycycline Celecoxib Bisphosphonates Statins Colchicine Hydroxychloroquine 13. Neutraceuticals Glucosamine sulphate Chondroitin sulphate Glycosaminoglycan polysulphate (arteparon) Curcumin Resveratol Anti-inflammatory factor (AIF) Phytalgic Fish oil Boigito Pomegranate Green tea Ginger Indian olibaum Turmeric Cats claw Devils claw Ananas 14. Glucosamine Eponym/ Authors Year HCl/S No. FU period Result summary S/N S GAIT 2010 GHCL 77 24 mo JSN: GH-0.013, Pl-0.166 NS Reginster 2001 GS 106 3 yrs GS-0.06 mm, Pl-0.31 S Pavelka 2002 GS 101 3 yrs GS-0.04 mm, Pl-0.19 mm S Poolsap review 2005 GS+ GHL >1 yr Pooled RR 0.46; 95% CI 0.28 to 0.73 S Wandels meta 2010 GS+ GHL 395 variable -0.2 mm (-0.3 to 0) NS 15. STOPP, 2009 16. Wildi et al, ARD, 2011 17. Chondroitin Sulfate Eponym/ Authors Year No. FU period Result summary S/NS Wildi, et al 2011 31 12 mo MRI CVL: CS: 3.71, Pl: 6.12 P=0.021 STOPP 2009 309 2 yr JSN: CS: 0.07, Pl: 0.31 P0.5mm D: 18.9, IAH: 17.7, P: 20.3 P=0.90 Fidelix meta Hip Knee 2009 1228 Variable Hip=0.04 Knee=0.85 23. Conclusions Body of evidences not enough Follow up period short Sample sizes small Structure modifying effects variable Where positive, effect size small 24. Guidelines NICE OARSI EULAR ACR 25. NICE Guidelines 26. ACR 2012 Non-Pharmacological: Strong Cardiovascular (aerobic) and/or resistance and land-based exercise Aquatic exercise Lose weight (for persons who are overweight) 27. ACR 2012 Non-Pharmacological: Conditional Medial taping of patella Medial wedging insole in lateral compartment OA Lateral wedging insole medial compartment OA Thermal agents Walking aids Tai chi programs 28. ACR 2012: Pharmacological Acetaminophen Oral NSAIDs Topical NSAIDs Tramadol IA steroids 29. ACR 2012: Pharmacological Should not use: Chondroitin sulfate Glucosamine Topical capsaicin No recommendation: IA hyaluronans Duloxetine Opioids 30. Conclusions Structure modifying therapy with proven and unequivocal benefit: Although we are not there yet, we are getting much closer to realizing the dream. RF Loeser: Osteoarthritis: A disease of the joint as an organ. Arthritis & Rheumatism 2012: 64: 1697--1707