Osteoarthritis: Difference between revisions
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====Chondroitin==== | ====Chondroitin==== | ||
A [[meta-analysis]] of [[randomized controlled trial]]s found no benefit from [[chondroitin]].<ref name="pmid17438317">{{cite journal |author=Reichenbach S, Sterchi R, Scherer M, ''et al'' |title=Meta-analysis: chondroitin for osteoarthritis of the knee or hip |journal=Ann. Intern. Med. |volume=146 |issue=8 |pages=580-90 |year=2007 |pmid=17438317 |doi=}}</ref> This [[meta-analysis]] included the GAIT [[randomized controlled trial]] of Clegg et al.<ref name="pmid16495392">{{cite journal |author=Clegg DO, Reda DJ, Harris CL, ''et al'' |title=Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis |journal=N. Engl. J. Med. |volume=354 |issue=8 |pages=795–808 |year=2006 |month=February |pmid=16495392 |doi=10.1056/NEJMoa052771 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16495392&promo=ONFLNS19 |issn=}}</ref> A longer followup of the GAIT show no benefit from sodium chondroitin on reduction in loss of joint space width.<ref name="pmid18821708">{{cite journal |author=Sawitzke AD, Shi H, Finco MF, ''et al'' |title=The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial |journal=Arthritis Rheum. |volume=58 |issue=10 |pages=3183–91 |year=2008 |month=October |pmid=18821708 |doi=10.1002/art.23973 |url=http://dx.doi.org/10.1002/art.23973 |issn=}}</ref> | A [[meta-analysis]] of [[randomized controlled trial]]s found no benefit from [[chondroitin]].<ref name="pmid17438317">{{cite journal |author=Reichenbach S, Sterchi R, Scherer M, ''et al'' |title=Meta-analysis: chondroitin for osteoarthritis of the knee or hip |journal=Ann. Intern. Med. |volume=146 |issue=8 |pages=580-90 |year=2007 |pmid=17438317 |url=http://www.annals.org/cgi/content/full/146/8/580|doi=}}</ref> This [[meta-analysis]] included the GAIT [[randomized controlled trial]] of Clegg et al.<ref name="pmid16495392">{{cite journal |author=Clegg DO, Reda DJ, Harris CL, ''et al'' |title=Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis |journal=N. Engl. J. Med. |volume=354 |issue=8 |pages=795–808 |year=2006 |month=February |pmid=16495392 |doi=10.1056/NEJMoa052771 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16495392&promo=ONFLNS19 |issn=}}</ref> A longer followup of the GAIT show no benefit from sodium chondroitin on reduction in loss of joint space width.<ref name="pmid18821708">{{cite journal |author=Sawitzke AD, Shi H, Finco MF, ''et al'' |title=The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial |journal=Arthritis Rheum. |volume=58 |issue=10 |pages=3183–91 |year=2008 |month=October |pmid=18821708 |doi=10.1002/art.23973 |url=http://dx.doi.org/10.1002/art.23973 |issn=}}</ref> | ||
A more recent trial is positive. A trial sponsored by the manufacturer reports less loss of joint space with [[chondriotin]]s 4 and 6.<ref name="pmid19180484">{{cite journal |author=Kahan A, Uebelhart D, De Vathaire F, Delmas PD, Reginster JY |title=Long-term effects of chondroitins 4 and 6 sulfate on knee osteoarthritis: The study on osteoarthritis progression prevention, a two-year, randomized, double-blind, placebo-controlled trial |journal=Arthritis Rheum. |volume=60 |issue=2 |pages=524–33 |year=2009 |month=February |pmid=19180484 |doi=10.1002/art.24255 |url=http://dx.doi.org/10.1002/art.24255 |issn=}}</ref> | A more recent trial is positive. A trial sponsored by the manufacturer reports less loss of joint space with [[chondriotin]]s 4 and 6.<ref name="pmid19180484">{{cite journal |author=Kahan A, Uebelhart D, De Vathaire F, Delmas PD, Reginster JY |title=Long-term effects of chondroitins 4 and 6 sulfate on knee osteoarthritis: The study on osteoarthritis progression prevention, a two-year, randomized, double-blind, placebo-controlled trial |journal=Arthritis Rheum. |volume=60 |issue=2 |pages=524–33 |year=2009 |month=February |pmid=19180484 |doi=10.1002/art.24255 |url=http://dx.doi.org/10.1002/art.24255 |issn=}}</ref> | ||
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! Chondroitin!!Placebo | ! Chondroitin!!Placebo | ||
|- | |- | ||
| GAIT<ref name="pmid16495392"/><br/>2007 || 1583 patients with knee | | GAIT<ref name="pmid16495392"/><br/>2007 || 1583 patients with knee osteoarthritis|| 1200 mg of chondroitin sulfate daily|| Response of 20% decrease in WOMAC pain score<ref name="pmid3068365">{{cite journal |author=Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW |title=Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee |journal=J. Rheumatol. |volume=15 |issue=12 |pages=1833–40 |year=1988 |month=December |pmid=3068365 |doi= |url= |issn=}}</ref> at 24 weeks|| 65%|| 60% | ||
|- | |- | ||
| GAIT<ref name="pmid18821708"/><br/>2008 || 1583 patients with knee | | GAIT<ref name="pmid18821708"/><br/>2008 || 1583 patients with knee osteoarthritis|| 1200 mg of chondroitin sulfate daily|| Loss of joint space width at two years|| 0.107 mm || 0.166 mm | ||
|- | |- | ||
| Kahan<ref name="pmid19180484"/><br/>2009<br/>Sponsored by manufacturer || 622 | | Kahan<ref name="pmid19180484"/><br/>2009<br/>Sponsored by manufacturer || 622 patientss with knee osteoarthritis<br/>32% dropped out|| 800 mg of chondroitin sulfate daily|| Loss at minimum joint space width<br/>Used last observation carried forward for dropouts|| 0.07 mm†|| 0.31 mm | ||
|- | |- | ||
| colspan="6"|† p < 0.05 | | colspan="6"|† p < 0.05 | ||
Revision as of 17:36, 27 February 2009
Diagnosis
Signs and symptoms
Knee osteoarthritis
Osteoarthritis of the knees is associated with buckling, or sudden giving way, of the knees.[1] This is more likely if the quadriceps muscle is weak.
A screening survey is positive if any one of the following is answered yes:[1]
- During the last 4 weeks, have you had knee pain on most days?
- During the last 4 weeks, have you had knee pain while climbing down stairs or walking down slopes?
- During the last 4 weeks, have you had swelling in one or both knees?
- Do you have knee OA? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)
- sensitivity = 87%
- specificity = 92%
Using the prevalence of disease in this study (5% to 8%), the predictive values are:
- positive predictive value = 51%
- negative predictive value = 98%
Hip osteoarthritis
A screening survey is positive if any one of the following is answered yes:[1]
- During the last 4 weeks, have you had hip pain (groin or upper thigh) on most days?
- During the last 4 weeks, have you had hip pain while climbing down stairs or walking down slopes?
- During the last 4 weeks, have you noticed any limitation in the range of motion of one or both hips?
- Do you have hip osteoarthritis? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)
- sensitivity = 93%
- specificity = 95%
Using the prevalence of disease in this study (5% to 8%), the predictive values are:
- positive predictive value = 56%
- negative predictive value = 99%
Treatment
Medications
Acetaminophen
A randomized controlled trial comparing acetaminophen to ibuprofen in x-ray proven mild to moderate osteoarthritis of the hip or knee found that equal benefit.[2] However, acetaminophen at a dose of 4 grams per day can increase liver function tests.[3]
Supplements
Dietary supplements have been studied.
Chondroitin
A meta-analysis of randomized controlled trials found no benefit from chondroitin.[4] This meta-analysis included the GAIT randomized controlled trial of Clegg et al.[5] A longer followup of the GAIT show no benefit from sodium chondroitin on reduction in loss of joint space width.[6]
A more recent trial is positive. A trial sponsored by the manufacturer reports less loss of joint space with chondriotins 4 and 6.[7]
| Trial | Patients | Intervention | Outcome | Results | |
|---|---|---|---|---|---|
| Chondroitin | Placebo | ||||
| GAIT[5] 2007 |
1583 patients with knee osteoarthritis | 1200 mg of chondroitin sulfate daily | Response of 20% decrease in WOMAC pain score[8] at 24 weeks | 65% | 60% |
| GAIT[6] 2008 |
1583 patients with knee osteoarthritis | 1200 mg of chondroitin sulfate daily | Loss of joint space width at two years | 0.107 mm | 0.166 mm |
| Kahan[7] 2009 Sponsored by manufacturer |
622 patientss with knee osteoarthritis 32% dropped out |
800 mg of chondroitin sulfate daily | Loss at minimum joint space width Used last observation carried forward for dropouts |
0.07 mm† | 0.31 mm |
| † p < 0.05 | |||||
Glucosamine
A molecule derived from glucosamine is used by the body to make some of the components of cartilage and synovial fluid.
Neither glucosamine sulfate[9] nor glucosamine hydrochloride[5][6] is effective for osteoarthritis.
S-adenosylmethionine
Acupuncture
Acupuncture is probably not effective according to a meta-analysis that concluded "sham-controlled trials show clinically irrelevant short-term benefits of acupuncture for treating knee osteoarthritis. Waiting list-controlled trials suggest clinically relevant benefits, some of which may be due to placebo or expectation effects."[10]
Injections
Injections of the hip joint for labral tears may not be effective.[11]
Surgery
Arthroscopic surgery for osteoarthritis of the knee is not effective according among patients with moderate or severe disease to two randomized controlled trials. However, a number of patients including those with severe disease of two or more compartments of the knee, were excluded.[12][13]
Prognosis
Knee
The strongest predictors of poor functional outcome are age, body mass index, anxiety and pain severity.[14]
Hip
Among patients presenting with hip pain to their general practitioner, the rates of total hip replacement are:[15]
- 12% of patients at 3 years
- 22% after 6 years
Predictors of the need for a total hip replacement are:[15]
- age >/=60 years, morning stiffness
- pain in the groin/medial thigh
- decreased extension/adduction
- painful internal rotation
- body mass index </=30 kg/m(2)
- Kellgren/Lawrence grade of 2 or higher
References
- ↑ 1.0 1.1 1.2 Felson, David T., Jingbo Niu, Christine McClennan, Burton Sack, Piran Aliabadi, David J. Hunter, et al. 2007. Knee Buckling: Prevalence, Risk Factors, and Associated Limitations in Function. Ann Intern Med 147, no. 8 (October 16): 534-540. http://www.annals.org/cgi/content/abstract/147/8/534 (accessed October 16, 2007). Cite error: Invalid
<ref>tag; name "pmidpending" defined multiple times with different content Cite error: Invalid<ref>tag; name "pmidpending" defined multiple times with different content - ↑ Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI (1991). "Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee". N. Engl. J. Med. 325 (2): 87-91. PMID 2052056. [e]
- ↑ Watkins PB, Kaplowitz N, Slattery JT, et al (2006). "Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial". JAMA 296 (1): 87-93. DOI:10.1001/jama.296.1.87. PMID 16820551. Research Blogging.
- ↑ Reichenbach S, Sterchi R, Scherer M, et al (2007). "Meta-analysis: chondroitin for osteoarthritis of the knee or hip". Ann. Intern. Med. 146 (8): 580-90. PMID 17438317. [e]
- ↑ 5.0 5.1 5.2 Clegg DO, Reda DJ, Harris CL, et al (February 2006). "Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis". N. Engl. J. Med. 354 (8): 795–808. DOI:10.1056/NEJMoa052771. PMID 16495392. Research Blogging.
- ↑ 6.0 6.1 6.2 Sawitzke AD, Shi H, Finco MF, et al (October 2008). "The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial". Arthritis Rheum. 58 (10): 3183–91. DOI:10.1002/art.23973. PMID 18821708. Research Blogging.
- ↑ 7.0 7.1 Kahan A, Uebelhart D, De Vathaire F, Delmas PD, Reginster JY (February 2009). "Long-term effects of chondroitins 4 and 6 sulfate on knee osteoarthritis: The study on osteoarthritis progression prevention, a two-year, randomized, double-blind, placebo-controlled trial". Arthritis Rheum. 60 (2): 524–33. DOI:10.1002/art.24255. PMID 19180484. Research Blogging.
- ↑ Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (December 1988). "Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee". J. Rheumatol. 15 (12): 1833–40. PMID 3068365. [e]
- ↑ Rozendaal RM, Koes BW, van Osch GJ, et al (February 2008). "Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial". Ann. Intern. Med. 148 (4): 268–77. PMID 18283204. [e]
- ↑ Manheimer E, Linde K, Lao L, Bouter LM, Berman BM (June 2007). "Meta-analysis: acupuncture for osteoarthritis of the knee". Ann. Intern. Med. 146 (12): 868–77. PMID 17577006. [e]
- ↑ Martin RL, Irrgang JJ, Sekiya JK (September 2008). "The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates". Arthroscopy 24 (9): 1013–8. DOI:10.1016/j.arthro.2008.04.075. PMID 18760208. Research Blogging.
- ↑ Kirkley A, Birmingham TB, Litchfield RB, et al (September 2008). "A randomized trial of arthroscopic surgery for osteoarthritis of the knee". N. Engl. J. Med. 359 (11): 1097–107. DOI:10.1056/NEJMoa0708333. PMID 18784099. Research Blogging.
- ↑ Moseley JB, O'Malley K, Petersen NJ, et al (2002). "A controlled trial of arthroscopic surgery for osteoarthritis of the knee". N. Engl. J. Med. 347 (2): 81–8. DOI:10.1056/NEJMoa013259. PMID 12110735. Research Blogging.
- ↑ Elaine Thomas et al., “Predicting the course of functional limitation among older adults with knee pain: do local signs, symptoms and radiographs add anything to general indicators?,” Ann Rheum Dis (February 4, 2008): ard.2007.080945.
- ↑ 15.0 15.1 Lievense AM, Koes BW, Verhaar JA, Bohnen AM, Bierma-Zeinstra SM (2007). "Prognosis of hip pain in general practice: A prospective followup study". Arthritis Rheum 57 (8): 1368–1374. DOI:10.1002/art.23094. PMID 18050175. Research Blogging.