Download Public Health Education Campaign (PHEC)

The ten minute management
of osteoarthritis
Managing OA in Primary Care:
maximising patient consultation time
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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
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
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
Management options5: EULAR guidelines
6. Non-pharmacological management strategies
should be incorporated
7. Paracetamol and NSAIDs should be used as firstline 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
Key principle 1
Patient-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
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
Key principle 3
Using 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
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
Stabbing
====
°°°°°°
xxxxxxxx
///////
Rating scales
•
Visual analogue scale
No
pain
•
Worst
possible
pain
Pain intensity
0
1
2
3
4
5
No pain
Mild
Discomforting
Distressing
Horrible
Excruciating






Key principle 4
Patient 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
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: [email protected]
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
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
Key principle 5
Management options
• Treatment should be a combination of nonpharmacological and pharmacological
measures5
• Indirect evidence suggests nonpharmacological treatments offer additional
benefits over and above treatment with
NSAIDs and analgesics5
Management option 6
Non-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
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
Aromatherapy
Hydrotherapy
Osteopathy
Tai chi
Alexander technique
Chiropractice
Massage
Reflexology
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
Management option 7
Analgesia 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)
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 COX2 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, anticoagulants)
– See over for updated Cox-2 prescribing guidelines
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
Management option 8
Symptomatic 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
Management option 9
Corticosteroid 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
Management option 10
Surgery
• 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
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 Rheumatism
http://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
References 1-9
1.
2.
3.
4.
5.
6.
7.
8.
9.
Arthritis Care. 1 in 5 – The prevalence and impact of arthritis in the UK (Research report).
February 2002.
Disability Care and Mobility Quarterly Statistical Enquiry - Disability Living Allowance,
Attendance Allowance and Invalid Care Allowance. Dept of Work and Pensions 2002.
Watson M. Management of patients with osteoarthritis. Pharm J 1997;259:296-297.
Royal College of General Practitioners OPCS Department of Health and Social Security.
Morbidity statistics from General Practice. Fourth National Survey 1991-1992. HMSO,
1996.
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.
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.
Creamer P, Lethbridge-Cejku M, Hochberg MC. Factors associated with functional
impairment in symptomatic knee osteoarthritis. Rheumatology 2000;39:490-496.
Walker-Bone K, Javaid K, Arden N et al. Regular review: Medical management of
osteoarthritis. BMJ 2000;321:936-940.
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.
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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Tel: 020 7380 6500 Fax:020 7380 6505
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Supported by an educational grant from
AC April 06