Osteoarthritis: Research, Prevention and Treatment

1. Osteoarthritis: Research, Prevention and Treatment David Hunter, MBBS PhD Osteoarthritis Research Society International Chief of Research, New England Baptist Hospital Associate Professor of Medicine, Tufts University

2. Disclosure • Dr Hunter receives grant support from NIH, MERCK, AstraZeneca, Wyeth, Pfizer, EliLilly, Stryker and DonJoy. • Dr Hunter is a consultant for NicOx, Wyeth and Smith and Nephew. • Dr Hunter receives royalties from DonJoy.

3. Outline • Prevention • Risk Factors for OA • Modifiable Risk Factors • Management of OA • Management Challenges

4. Dieppe PA, Lohmander S. The Lancet. 2005; Vol 365; 965-973

5. Our continuing evolution-aging and obesity

6. Knee OA Prevention Arthritis Rheum. 1998, Aug;41(8):1343-55. Osteoarthritis Cartilage. 2009; Sep 2.

7. Prevention: The time is now • Injury • Lifetime risk of knee OA is 57% among persons with a history of prior knee injury, and specific injuries, such as anterior cruciate ligament (ACL) ruptures and ankle fractures, have been clearly linked to incident OA. • Arthritis Rheum, 2008;59(9):1207-1213. • Neuromuscular conditioning programs have demonstrated effectiveness in reducing the risk of ACL injury by 60%. • Am J Sports med, 2006;34(3):490-8. • Obesity • Promote policies, initiatives and state and national partnerships to help all young people achieve and maintain a healthy weight, thereby potentially reducing their risk for developing OA. • http://www.surgeongeneral.gov/topics/obesity/ • The National Public Health Agenda for Osteoarthritis. Combined action of AF and CDC.

8. Aims of Management Patient education about both the disease and its management Pain control Improvement of function Alteration of the disease process and its consequences

9. Algorithm for OA Management

10. Patient education Self-management programs Weight loss (if overweight or obese) Aerobic exercise programs Physical therapyMuscle-strengthening exercises Assistive devices for ambulationPatellar tapingAppropriate footwear Medial-wedged insoles (for genu valgum) BracingOccupational therapyJoint protection and energy conservation Assistive devices for activities of daily living Pharmacologic intervention Surgical intervention Therapeutic Advances in Musculoskeletal Diseases 1: 35-47

11. Symptom relief challenges • Areas for improvement – Efficacy » Modest effect size of NSAIDs » Poor short- and long-term relief – Safety/Tolerability » Narrow therapeutic benefit of COXIBs over NSAIDs » Comorbidities carry enhanced risks of DDI/SAEs • Pain is often under treated

12. Reducing the burden of OA Disease Progression Prevention Symptomatic Treatment

13. Guidelines→ clinical practice • Numerous recent guidelines with substantive merit. • OARSI. Osteoarthritis & Cartilage. 2008; 16:137-162 • EULAR. Annals of the Rheumatic Diseases 64:669-681 • AAOS. J Am Acad Orthop Surg. 2009 17: 591-600. • Little relation between clinical practice and management practices recommended in guidelines. • Great need for dissemination, translation and quality indicators.

14. Non-evidence based inadequate care Numerous studies have documented standard clinical practice is focused upon analgesia using pharmacologic agents and when this fails surgery. These studies document: inadequate uptake of conservative, non-pharmacologic treatment options such as weight loss and exercise (both important risk factors that are capable of modifying the course of the disease), inappropriate surgical interventions such as arthroscopic debridement and lavage and the inappropriate use of imaging. DeHaan MN, Guzman J, Bayley MT, Bell MJ: Knee osteoarthritis clinical practice guidelines -- how are we doing?Journal of Rheumatology 2007, 34: 2099-2105. Pencharz JN, Grigoriadis E, Jansz GF, Bombardier C: A critical appraisal of clinical practice guidelines for the treatment of lower-limb osteoarthritis. Arthritis Research 2002, 4: 36-44. Jawad AS: Analgesics and osteoarthritis: are treatment guidelines reflected in clinical practice?.American Journal of Therapeutics 2005, 12: 98-103. Glazier RH, et al.: Management of common musculoskeletal problems: a survey of Ontario primary care physicians.CMAJ Canadian Medical Association Journal 1998, 158: 1037-1040.

15. Concomitant comorbidities Of the 125 million Americans with chronic diseases, 48% are estimated to have at least one comorbidity, and 62% of persons over the age of 65 have two or more chronic illnesses. Persons with OA: 65% are overweight/ obese 40% have hypertension 15% have diabetes These comorbidities further compound management challenges and are frequently ignored in current management approaches. Jain RK, McCormick JC: Archives of Internal Medicine 2004, 164: 807. G, Miller JD, Lee FH, Pettitt D, Russell MW: American Journal of Managed Care 2002, 8: S383-S391. Messier SP, et al.: Arthritis & Rheumatism 2005, 52: 2026-2032.

16. Costs are rising According to the US Centers for Disease Control (CDC), arthritis and other rheumatic conditions (AORC) cost the US $128 billion in 2003, a 24% surge since 1997 and an amount equal to 1.2% of the gross domestic product (GDP).

17. Consequence As a result of inadequate care many patients are dissatisfied. Many are turning to untested and aggressively marketed dietary supplements with little substantive evidence to support their efficacy. Many patients are turning to the internet for healthcare information but how does the consumer know what is a credible source of information? Chard J, et al: Rheumatology 2002, 41: 1208-1210. Rosemann T, et al: BMC Musculoskeletal Disorders 2006, 7: 48. Burks K:Orthopaedic Nursing 2002, 21: 28-34. Neville C, et al.: Arthritis Care & Research 1999, 12: 85-95. Gardiner P, et al: Alternative Therapies in Health & Medicine 2007, 13: 22-29.

18. Conclusions • OA prevention-we know what needs to be done but at this point there is little action. • OA Management • Adequate pain control still unmet need • Dichotomy between guidelines and clinical practice.

19. Acknowledgements