Review of osteoarthritis, the most common joint disease in the world.
Developing
Osteoarthritis (OA) is the most common joint disease in the world. It is the result of mechanical changes and biological events that destabilize the balance between degradation and normal synthesis of articular cartilage, extracellular matrix and subchondral bone (Photo 1). It is said that OA is primary when there is no association with any underlying disease, and it is secondary when it is related to another condition . The most affected joints in primary OA are: cervical and lumbar spine, proximal and distal interphalangeal of hands, hips, knees, first metatarsophalangeal and interphalangeal of feet .
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The predominant symptom in OA is pain, which can be localized in the joint or referred, as in the case of hip OA, where there may be pain in the knee. Pain in OA is associated with joint movement and weight burden and decreases with rest. At the beginning it is usually intermittent and of mild to moderate intensity; later (usually years) it can be constant and of severe and disabling intensity. Other symptoms and signs are shown in Table 2. Radiographs are the most accessible imaging method in clinical practice for the diagnosis, staging of severity and evaluation of the progression of OA. However, patients with radiographic changes typical of OA do not always have symptoms. In a study conducted in the United Kingdom, a 17% prevalence of OA in the knee was detected among women aged 45-65 years, of whom only 2.3% had symptoms.
So far there are no treatments that have clinically proven to regenerate cartilage, so the main objective of currently available therapies is to improve the symptoms related to OA (pain specifically). Pain in OA is usually nociceptive and, as in all pain, treatment should be directed not only to intervene in the somatic components of the pain, but also to influence the cognitive components (beliefs, moods and behaviors). The treatment of pain in OA can be divided into non-pharmacological, pharmacological and surgical.
Non-pharmacological measures
Patient education programs are cost-effective. The most effective education plan is one that seeks to modify the behavior of the individual, help him to understand his illness, to make decisions about his therapy by means of the adequate information and to have adherence to the treatment plan. Patients with OA benefit from exercise, either directed to the affected joints and / or with aerobic conditioning exercises in general. Several studies have shown that pain decreases thanks to exercises carried out under supervision or with programs to be carried out at home.
It is necessary that obese people with knee or hip OA reduce their weight. Obesity is a risk factor associated with OA of the knee and hip. When losing weight, symptomatic patients with knee OA, even in a modest percentage, have less pain. The use of mechanical supports has been useful in controlled studies. Using a cane with the hand contralateral to the affected joint, either knee or hip, serves to reduce overload up to 60% in the case of the hip, which significantly relieves pain. The use of side heels, knee pads and patellar bands helps in specific situations, such as medial knee pain, instability or chondromalacia, respectively.
The use of cold-heat in different modalities (electrostimulation, acupuncture) is a recommended therapy to reduce pain in OA, although there are no controlled studies to prove its effectiveness.
Pharmacotherapy
Non-opioid analgesics Paracetamol at a dose of 1 g four times a day is useful to reduce pain in a large percentage of patients with OA. It has considerable pharmacological safety and is well tolerated. It is the medication of choice recommended by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) for the treatment of OA. The use of topical capsaicin (red chile component, substance P depletor) has been shown to reduce pain in controlled studies against placebo.
Opioid analgesics There are studies on the use of tramadol vs. Naproxen in which the decrease in the use of the latter and the combination of tramadol with paracetamol has been detected, which enhances the analgesic effect. The use of opioid analgesics in non-oncological pain is controversial due to possible dependence and its side effects (nausea, sedation, dizziness, constipation), so it is only recommended in patients in whom another type of analgesia has failed.
Non-steroidal anti-inflammatories (NSAIDs) . They are indicated in people who have not responded favorably to paracetamol. Some studies have concluded that NSAIDs are as effective as acetaminophen and others are superior to it. All the investigations available to date have been performed in the short term (less than six months), hence it is recommended to use them for short periods, assessing their potential unwanted side effects, particularly the risk of bleeding and others (lack of control of arterial hypertension). , heart and kidney failure). The use of misoprostol or proton pump inhibitors reduces the risk of gastrointestinal complications.
Symptomatic slow-acting drugs in OA (SYSADOA, symptomatic slow action drugs osteoarthritis).
The SYSADOA are a group of drugs that have proven their usefulness in OA by reducing pain and improving other symptoms. As the name implies, they have their clinical effect after months of use. Theoretically, they could modify the disease, but there are still no conclusive clinical studies.
Glucosamine It is a glycoprotein component of the articular cartilage matrix. Certain studies conducted with glucosamine sulfate have proven effective in reducing pain and improving joint function in mild to moderate knee OA. The necessary dose is 1,500 mg / day; its effects begin to be noticeable until three months after the start of treatment. There are studies in which glucosamine has been used for up to three years with good pharmacological safety.
Coindritin sulfate . It is a normal component proteoglycan of articular cartilage. Like glucosamine, it has proven to be effective in reducing pain in knee OA. The recommended dose is 1,200 mg / day. Currently, it is found mainly in presentations in combination with glucosamine.
Diacerein . It is a drug that blocks IL-1, so it has an anti-inflammatory effect. In addition, it increases the production of the growth factor. This medication decreases symptoms and improves joint function in OA of the knee and hip. The recommended dose is 100 mg / day.
Unsaponified soybean / avocado oils . Initial research comes from France, where several controlled studies give it inhibitory properties, significantly reducing the progression of hip loss, compared to placebo. These oils improve symptoms and joint function in OA of the knee and hip, 6 since they inhibit IL-1 and metalloproteinases and increase aggrecan concentrations. The suggested dose is 300 mg / day for an indefinite period.
Intra-articular therapy
Intra-articular steroids The guidelines for the treatment of EULAR and ACR in knee OA accept that the application of intraarticular steroids are useful to relieve short-term pain in knees with joint effusion. It is believed that steroids have therapeutic effects for short periods (weeks) and that they could damage the articular cartilage, although there is a study that contradicts this. Still can not establish a consensus on this.
Hyaluronic acid . This is a normal component of synovial fluid and an important glycoprotein in joint homeostasis. Theoretically, the intra-articular application of this acid in the knee restores the viscoelasticity of the synovial fluid in the OA and promotes the endogenous synthesis of the hyaluronic acid of high molecular weight. Through some studies it has been shown that hyaluronic acid decreases pain in the knee at 3-5 weeks of its application; this effect persists for 3-6 months. However, other investigations do not consider it superior to placebo. At present, repetitive intra-articular injections are only administered if there was a favorable response in the first course of applications.
Surgical treatment in OA . When non-pharmacological and pharmacological measures do not offer adequate control of pain and related symptoms, the required treatment is surgical. Joint washing and debridement may improve symptoms in some cases. Osteotomy in the recent OA of the knee can relieve symptoms and slow progression. A last resort is arthrodesis, which usually controls pain in some joints (carpus, spine, foot). Arthroplasty is necessary in severe OA (whose pain is disabling), removes pain and offers functional articulation for approximately 20 years.
Conclusions
OA is the most prevalent joint disease in the world. Pain is the most important symptom of this condition. The management of pain in OA should consider the cognitive and somatic aspects of it. No drugs are yet available that regenerate the articular cartilage, so relieving pain is one of the main objectives in the treatment of OA, with the subsequent improvement in quality of life. Nowadays there are non-pharmacological, pharmacological and surgical measures for the adequate treatment of this entity, which should be used according to the characteristics of each patient.