Degenerative Joint Disease

Dan O’Connell, MD

Montefiore Medical Center

Dept. of Family Medicine

What can I do for my aching knees?

DJD and knee sleeves http://www.cochrane.de/cc_bin/mno?q=nsaid&m=all&ul=http%3A%2F%2Fwww.cochrane.org

Authors' conclusions: Based on one brace study we conclude there is limited evidence that:a brace has additional beneficial effect (WOMAC, MACTAR, function tests) for knee osteoarthritis compared with medical treatment alone.(Silver) a sleeve has additional beneficial effect (WOMAC, function tests) for knee osteoarthritis compared with medical treatment alone.(Silver)a brace is more effective (WOMAC, function tests) than a neoprene sleeve.(Silver) Based on 3 orthoses studies, of which 2 were high quality, (n=2) we conclude there is limited evidence that: a laterally wedged insole decreases NSAID intake compared with a neutral insole. (Silver)patient compliance is better in the laterally wedged insole compared with a neutral insole. (Silver)a strapped insole has more adverse effects than a lateral wedge insole. (Silver)

ArthoscopyAuthors' conclusions: Based on

11 studies, of which 6 were high quality, there is no evidence whether an osteotomy is more effective than conservative treatment and the results so far do not justify a conclusion about effectiveness of specific surgical techniques.

Ultrasound treatment Authors' conclusions: Ultrasound therapy

appears to have no benefit over placebo or short wave diathermy for people with hip or knee OA. These conclusions are limited by the poor reporting of the characteristics of the device, the population, the stage of OA, therapeutic application of the ultrasound and overall low methodological quality of the trials included. No conclusions can be drawn about the use of ultrasound in smaller joints such as the wrist or hands.

Authors' conclusions: The evidence to date suggests that NSAIDs are superior to acetaminophen for improving knee and hip pain in people with OA but have not been shown to be superior in improving function. The size of the treatment effect was modest, and the mean trial duration was only six weeks, therefore, additional considerations need to be factored in when making the decision between using acetaminophen or NSAIDs. In OA subjects with moderate-to-severe levels of pain, NSAIDs appear to be more effective than acetaminophen.

Herbal therapy – avocado/soybean

Main results: Five studies (four different herbal interventions) met the review criteria. Two studies were suitable for data pooling. It was not possible to draw firm conclusions from the single studies but the two combined studies of avocado/soybean unsaponifiables showed beneficial effects on functional index, pain, intake of non-steroidal anti-inflammatory drugs (NSAIDs) and global evaluation. No serious side effects were reported.

Glucosamine and DJD Authors' conclusions: Further research is necessary

to confirm the long term effectiveness and toxicity of glucosamine therapy in OA. It is not known whether different glucosamine preparations prepared by different manufacturers are equally effective in the therapy of OA.

Citation: Towheed TE, Anastassiades TP, Shea B, Houpt J, Welch V, Hochberg MC. Glucosamine therapy for treating osteoarthritis. The Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD002946. DOI: 10.1002/14651858.CD002946.

What’s the best medicine for my knee pain?

Are their any side effects?

Is there anything to prevent the side effects?

In a 1999 analysis, NSAIDs accounted for more than 16,000 deaths and 100,000 hospitalizations each year.9 

9.  Wolfe, MM, Lichtenstein, DR, Singh, G.  Gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs.  New England Journal of Medicine 1999;340(24):1888?]99.

9.  Wolfe, MM, Lichtenstein, DR, Singh, G.  Gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs.  New England Journal of Medicine 1999;340(24):1888?]99.

Arachidonic acid

NSAID and COX2Which is the most efficacious for pain

relief?

Which has the least side effects?

Which is safest for the stomach?

Both NSAID and COX2Decrease renal blood flowSl increase Fluid retentionSl increase Blood pressureSl increased renal failure

Relative COX 2 selectivity

Most non-selective – Naprosyn, Ibuprofen

Relatively more selective - Salicylic acid

sulindac, namubetone (relafen)

Somewhat COX 2 selective - Celebrex

Most COX 2 selective – Vioxx, Bextra

Partially sellective NSAIDsFewer renal effects:

Salicylic acidSulindacNamubetone (relafen)

Cochrane – Preventing GI effects Authors' conclusions: Misoprostol,

PPIs, and double dose H2RAs are effective at preventing chronic NSAID related endoscopic gastric and duodenal ulcers. Lower doses of misoprostol are less effective and are still associated with diarrhea. Only Misoprostol 800ug/day has been directly shown to reduce the risk of ulcer complications such as perforation hemorrhage or obstruction

Misoprostol

200 mcg qid $150 for 120 tabs

Combo with Diclofenec (Arthrotec) 50/0.02 TID or 75/0.2 TID $150-160 for 90 tabs

S.E. – Nausea, diarrhea

Used in Medical TOP

Celebrex and Bextra

Bextra very similar to Vioxx – use with extreme caution for increased cardiac events

Celebrex is relatively less COX-2 selective than Vioxx or Bextra

Celebrex 100 mg BID or 200 QD cardiac events similar to placebo SO FAR (2005)

200 BID (Rheum arthritis dose) with increased cardiac events

ACETAMINOPHENGI side effects ?

Other side effects?

Efficacy relative to placebo?

Efficacy relative to NSAIDs?

Tramadol (Ultram) opiate agonist Norepinephrine/serotonin reuptake inh

Equivalent to acet/codeine

SE – Low risk SZ, esp c anti-psychotic or anti depressant – dose dependent

Dependence possible

Give combined with Acet or NSAID

PPIs and $$Omeprazole 20-40 mg $94

Prilosec 20-40 $115-$170

Nexium 20-40 $125m $123

Protonix 40mg $107

Prevacid 15-30 mg $125 for both

Prev/NapraPAC 15-500 mg $80 for 60

Axid 150-300 mg $80-160

Ranitidine 300 mg $13

AXID AR 75mg 60 for $20

Prilosec OTC 20 mg $23 for 28