Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

Knee Arthritis Treatments Ranked By Relative Effectiveness

Wear and tear on the knee joints creates pain for up to 40% of Americans over age 45. There are plenty of over-the-counter (OTC) and prescription (Rx) osteoarthritis treatments available, but how effective are they relative to one another? A new meta-analysis published by the Annals of Internal Medicine may shed some light on this important question. After 3 months of the following treatments, here is how they compared to one another in terms of power to reduce pain, starting with strongest first:

#1. Knee injection with gel (Rx hyaluronic acid)

#2. Knee injection with steroid (Rx corticosteroid)

#3. Diclofenac (Voltaren – Rx oral NSAID)

#4. Ibuprofen (Motrin – OTC oral NSAID)

#5. Naproxen (Alleve – OTC oral NSAID)

#6. Celecoxib (Celebrex – Rx NSAID)

#7. Knee injection with saline solution (placebo injection)

#8. Acetaminophen (Tylenol – OTC Synthetic nonopiate derivative of p-aminophenol)

#9. Oral placebo (Sugar Pill)

I found this rank order list interesting for a few reasons. First of all, acetaminophen and celecoxib appear to be less effective than I had believed. Second, placebos may be demonstrably more effective the more invasive they are (injecting saline into the knee works better than acetaminophen, and significantly better than sugar pills). Third, injection of a cushion gel fluid is surprisingly effective, especially since its mechanism of action has little to do with direct reduction of inflammation (the cornerstone of most arthritis therapies). Perhaps mechanical treatments for pain have been underutilized? And finally, first line therapy with acetaminophen is not clinically superior to placebo.

There are several caveats to this information, of course. First of all, arthritis pain treatments must be customized to the individual and their unique tolerances and risk profiles. Mild pain need not be treated with medicines that carry higher risks (such as joint infection or gastrointestinal bleeding), and advanced arthritis sufferers may benefit from “jumping the line” and starting with stronger medicines. The study is limited in that treatments were only compared over a 3 month trial period, and we cannot be certain that the patient populations were substantially similar as the comparative effectiveness was calculated.

That being said, this study will influence my practice. I will likely lean towards recommending more effective therapies with my future patients, including careful consideration of injections and diclofenac for moderate to severe OA, and ibuprofen/naproxen for mild to moderate OA, while shying away from celecoxib and acetaminophen altogether. And as we already know, glucosamine and chondroitin have been convincingly shown to be no better than placebo, so save your money on those pills. The racket is expected to blossom into a $20 billion dollar industry by 2020 if we don’t curb our appetite for expensive placebos.

In conclusion, the elephant in the room is that weight loss and exercise are still the very best treatments for knee osteoarthritis. Check out the American Academy of Orthopedic Surgery’s recent list of evidence-based recommendations for the treatment of knee arthritis for more information about the full spectrum of treatment options.

The Problem With Dermal Fillers

From Forbes:

But today, a range of dermal fillers can be injected into those crow’s feet, marionette lines, thinning lips and furrows between the brows, taking years off the face–and all can be done during your lunch hour, with no invasive surgery and little recovery time.
Source: forbes.com/2009/05/26/dermal-filler-cosmetic-forbes-woman-well-being-facelift.html

I love how the press tends to make it seem like Dermal Fillers are the solution for which we have all been waiting. They make it an issue of just “choosing the right one.”

The issue here is that dermal fillers Read more »

*This blog post was originally published at Truth in Cosmetic Surgery*

Liquid Material May Someday Be Used To Restore Damaged Soft Tissue

Yesterday, I came across this press release from Johns Hopkins regarding a new composite material which may someday be used to restore damaged soft tissue.  (photo credit)

The liquid material is a composite of biological and synthetic molecules which is injected under the skin.  Transdermal light is then used to “set” the material into a more solid structure.

The results of the early experiments in rats and humans has been reported in the July 27 issue of Science Translational Medicine (full reference below).

It is hoped that the new liquid material is a biosynthetic soft tissue replacement composed of poly(ethylene glycol) (PEG) and hyaluronic acid (HA).

From the press release Read more »

*This blog post was originally published at Suture for a Living*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »

Commented - Most Popular Articles