The ten minute management of osteoarthritis

1. The ten minute management of osteoarthritis Managing OA in Primary Care: maximising patient consultation time Supported by an educational grant from Merck Sharp & Dohme Limited

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3. Osteoarthritis: burden of disease • One in five people in the UK have arthritis1 • Arthritis is the largest single cause of physical disability in the UK2 • Osteoarthritis (OA) is the most common form of arthritis3 • OA is associated with considerable burden of disease – second only to cardiovascular disease in causing severe disability3

4. OA in Primary Care • Most patients with OA are managed in Primary Care4 • Overall, muscloskeletal problems account for one in ten (10%) of General Practice consultations4 • GPs have an opportunity to optimise patient care in OA

5. Key principles5: EULAR guidelines 1. Treatment should be tailored to the patient 2. The relationship between the healthcare team and the patient should be a two-way process 3. Using tools can help to assess the patient’s pain and disability 4. Patient education has a significant impact on pain management 5. Treatment should be a combination of non-pharmacological and pharmacological measures

6. Management options5: EULAR guidelines 6. Non-pharmacological management strategies should be incorporated 7. Paracetamol and NSAIDs should be used as first-line pharmacotherapy 8. There is evidence to support the use of some symptomatic slow-acting drugs for OA (SYSADOA) 9. Corticosteroid intra-articular injections can be useful in acute exacerbations 10. Consider surgery in patients unresponsive to medical management

7. Key principle 1Patient-tailored treatment • OA is a long-term, chronic condition and has a considerable impact on quality of life5 • Treatment should: • be tailored to the patient5 • consider the individual patient’s needs in terms of both functionality and of pain relief5 • It is likely that each individual patient will have to try a number of management options before finding the combination which works best for them5

8. Key principle 2 Doctor/patient relationship5 • The relationship between the healthcare team and the patient is key • The patient should be an active partner in disease management • Involve the patient in treatment decisions and listen to their concerns • The patient is an expert in their disease: they know their pain better than anyone else and will have developed strategies to deal with it

9. Key principle 3Using tools • Tools can help to assess the patient’s pain and disability • Tools include: • rating scales • questionnaires6 • pain diagrams • Using tools before and after treatment is also useful to determine whether treatment is working

10. Pain drawings Mark the area on your body where you feel the described sensations Use the appropriate symbol Mark the areas of radiation Include all affected areas Numbness = = = = Pins and needles ° ° ° ° ° ° Burning xxxxxxxx Stabbing / / / / / / /

11. Rating scales • Visual analogue scale No pain Worst possible pain • Pain intensity • 0 No pain  • 1 Mild  • 2 Discomforting  • 3 Distressing  • 4 Horrible  • 5 Excruciating 

12. Key principle 4Patient education • Studies suggest that education is around 20% as effective as NSAIDs, and can have a synergistic effect with other treatments8 • Patient information and self-management strategies can empower patients to take control of their arthritis • Effective education techniques include: • individual education packs • regular telephone calls • group education • patient coping skills • spouse assisted coping skills training5

13. Arthritis Care • Arthritis Care, 18 Stephenson Way, London, NW1 2HD • Telephone: 020 7380 6500 (switchboard) • Fax: 020 7380 6505 • www.arthritiscare.org.uk • Helpline • Freephone: 0808 800 4050 Monday-Friday,10 am - 4 pm • Email: Helplines@arthritiscare.org.uk

14. Arthritis Care Arthritis Care is the UK’s largest voluntary organisation working with and for all people with arthritis. It provides information and support on a range of issues related to living with arthritis. Arthritis Care campaigns locally and nationally to make sure people with arthritis have access to the treatments and services they deserve. In summary, we provide: • Helplines, support and courses to help patients manage their arthritis • Information and booklets on issues from benefits to treatments • A network of local information and support • Campaigns to change attitudes and laws to improve quality of life for those with arthritis • Self-management courses including Challenging Arthritis and the Positive Future workshops aimed at younger people

15. Arthritis Care FactSheets A full list of factsheets are available on the Arthritis Care website. Some of the factsheets we have are mentioned below: • Home treatment for pain relief: heated pads and cold packs • TENS machines: An electronic method of pain relief • Resources to help you exercise • Resources to help you manage your pain • COX-2 drugs: a patient question and answer sheet • Osteoarthritis of the hip

16. Key principle 5Management options • Treatment should be a combination of non-pharmacological and pharmacological measures5 • Indirect evidence suggests non-pharmacological treatments offer additional benefits over and above treatment with NSAIDs and analgesics5

17. Management option 6Non-pharmacological management • Life-style modification has an important role in management5,9 • For example5: • weight loss • exercise • quadriceps strengthening • range of movement • general fitness • hydrotherapy • assistive devices (canes and frames) • appropriate footwear, insoles

18. Management option 6 Non-pharmacological management • Little formal evidence to support complementary therapies, but some patients derive considerable benefit • Examples of complementary therapies include: Acupuncture Alexander technique Aromatherapy Chiropractice Hydrotherapy Massage Osteopathy Reflexology Tai chi

19. Management option 6 Non-pharmacological management • Self-management strategies can improve patients’ ability to manage their pain and disability of OA5 • Access to patient organisations and support groups which provide help and advice

20. Management option 7Analgesia and NSAIDs • Use paracetamol as first-line therapy5 • It is likely that the majority of patients will have already tried over-the-counter paracetamol5 • In those patients with a poor response to paracetamol, NSAIDs should be considered5 • NICE guidance recommends that COX-2 selective inhibitors should be considered only in patients who may be at high risk of developing serious gastro-intestinal (GI) adverse events10 • The European Medicines Agency advised doctors that Cox-2 selective inhibitors should only be prescribed to people with arthritis at ‘the lowest effective dose for the shortest possible duration’. (EMEA 27 June 2005)

21. Management option 7 (1)COX-2 selective inhibitors • Consider in patients who may be at high risk of developing serious GI adverse events, and in whom an NSAID is clearly indicated10 • High-risk patients include, those: • aged 65 years and over, • with a previous clinical history of gastroduodenal ulcer, GI bleeding or gastroduodenal perforation. The use of even a COX-2 selective agent should be considered especially carefully in this situation, • taking concomitant medication(s) that are known to increase the likelihood of upper GI adverse events (eg corticosteroids, anti-coagulants) • See over for updated Cox-2 prescribing guidelines

22. Management option 7 (2)COX-2 selective inhibitors • June 2005 – The European Medicines Agency reviewed Cox-2 selective inhibitors, they concluded that: • the risks of potential fatal skin reactions with Valdecoxib (Bextra) outweighed the benefits and suspended Valdecoxib for a year, pending a review. Pfizer voluntarily withdrew Valdecoxib • other Cox-2 selective inhibitors (Celecoxib, Etoricoxib, Lumiracoxib, Parecoxib) will have stronger guidelines for prescription: • Cox-2s should not be prescribed to people with ischaemic heart disease, cerebrovascular disease or peripheral arterial disease • caution when prescribing Cox-2s to people with heart disease, hypertension, hyperlipidaemia (cholesterol), diabetes and smokers • doctors are advised to prescribe the lowest effective Cox-2 dose for the shortest possible duration

23. Management option 8Symptomatic slow-acting drugs of OA • Symptomatic slow-acting drugs of OA (SYSADOA) • glucosamine • chondroitin • hyaluronic acid • Supported by increasing evidence, although further research is still required5,8,11,12 • Given that these agents appear to be well tolerated and do show some benefit their use should be considered13

24. Management option 9Corticosteroid injections • Corticosteroid intra-articular injections may be used in the management of patients with OA of the knee5 • Provide superior short-term efficacy (2-4 weeks) versus placebo8 • Recommended for acute exacerbations5

25. Management option 10Surgery • Refer for orthopaedic evaluation if patient is disabled by OA or in pain unrelieved by medical management5,9 • Joint replacement can be very effective5 • Newer techniques such as metal-on-metal resurfacing are less invasive15 • Patients should be made aware of the risks and benefits of surgery

26. Other useful resources Arthritis Research Campaign http://www.arc.org.uk Primary Care Rheumatology Society http://www.pcrsociety.com British Society for Rheumatology http://www.rheumatology.org.uk The European League Against Rheumatismhttp://www.eular.org National Library for Health – Musculoskeletal Library http://libraries.nelh.nhs.uk/musculoskeletal Primary Care Question & Answer Service http://www.clinicalanswers.nhs.uk/index.cfm

27. References 1-9 1. Arthritis Care. 1 in 5 – The prevalence and impact of arthritis in the UK (Research report).February 2002. 2. Disability Care and Mobility Quarterly Statistical Enquiry - Disability Living Allowance, Attendance Allowance and Invalid Care Allowance. Dept of Work and Pensions 2002. 3. Watson M. Management of patients with osteoarthritis. Pharm J 1997;259:296-297. 4. Royal College of General Practitioners OPCS Department of Health and Social Security. Morbidity statistics from General Practice. Fourth National Survey 1991-1992. HMSO, 1996. 5. Jordan KM, Arden NK, Doherty M et al. 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. 6. Dawson J, Fitzpatrick R, Murray D et al. Questionnaire on the perceptions of patients about total knee replacement. J Bone Joint Surg (Br) 1998;80:63-69. 7. Creamer P, Lethbridge-Cejku M, Hochberg MC. Factors associated with functional impairment in symptomatic knee osteoarthritis. Rheumatology 2000;39:490-496. 8. Walker-Bone K, Javaid K, Arden N et al. Regular review: Medical management of osteoarthritis. BMJ 2000;321:936-940. 9. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000;43(9):1905-1915.

28. References 10-15 10. Guidance on the use of cyclo-oxygenase (COX) II selective inhibitors, celecoxib, rofecoxib, meloxicam and etodolac for osteoarthritis and rheumatoid arthritis. NICE Technology Appraisal Guidance 27, July 2001. 11. Deal CL, Moskowitz RW. Nutraceuticals as therapeutic agents in osteoarthritis. The role of glucosamine, chondroitin sulfate and collagen hydrolysate. Rheum Clin N Am 1999;25:379-395 12. Is glucosamine worth taking for osteoarthritis. Drug & Ther Bull 2002;40:81-83. 13. Chard J, Dieppe P. Glucosamine for osteoarthritis: Magic, hype, or confusion? It's probably safe-but there's no good evidence that it works. BMJ 2001;322(7300):1439-1440. 14. Guidance on the selection of prostheses for primary total hip replacement. NICE Technology Appraisal Guidance 2, April 2000. 15. Guidance on the use of metal on metal hip resurfacing arthroplasty. NICE Technology Appraisal Guidance 44, June 2002.

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