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.
Severe osteoarthritis of the hands
One of my patients came to see me today with severe right knee pain. This is not a new problem, and in fact, we have been dealing with flare ups of her osteoarthritis for years. It mainly affects her knees and hands and today her right knee was swollen and felt like the “bone was rubbing together” with each step. She could hardly walk because of the pain.
Osteoarthritis is also known as degenerative arthritis and it is one of the most common maladies of aging joints, affecting millions of people. The cartilage in joints wears down and inflammation causes the bones to build up spurs and small micro tears. It affects women more than men and the cause is unknown. There are likely genetic factors as it tends to run in families. Arthritis can occur in any joint but the most common are the fingers, wrists, hips, neck and spine and knees. Stiffness (especially in the morning) and pain are the main symptoms that limit mobility.
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*This blog post was originally published at EverythingHealth*
Glucosamine is widely used for osteoarthritis pain. It’s not as impossible as homeopathy, but its rationale is improbable. As I explained in a previous post:
Wallace Sampson, one of the other authors of this blog, has pointed out that the amount of glucosamine in the typical supplement dose is on the order of 1/1000th to 1/10,000th of the available glucosamine in the body, most of which is produced by the body itself. He says, “Glucosamine is not an essential nutrient like a vitamin or an essential amino acid, for which small amounts make a large difference. How much difference could that small additional amount make? If glucosamine or chondroitin worked, this would be a medical first and worthy of a Nobel. It probably cannot work.”
Nevertheless, glucosamine (alone or with chondroitin) is widely used, and there are some supporting studies. But they are trumped by a number of well-designed studies that show it works no better than placebo, as well as a study showing that patients who had allegedly responded to glucosamine couldn’t tell the difference when their pills were replaced with placebos. Read more »
*This blog post was originally published at Science-Based Medicine*
One of my patients is an elderly woman who is completely bedbound due to osteoarthritis. Since she’s considered “too old,” she isn’t considered a surgical candidate for a knee replacement. Her son, George, is her caregiver.
George had been referred to our practice through word-of-mouth from a geriatric care consultant. When he called me for an initial visit, his mother had a spot on her left forearm that was growing rapidly. The nodule was red and tender. Both of them wanted a doctor to look at and remove it, and at the house if possible. Read more »
Back to the subject at hand.
To those who are relatively new to this blog, one of the most popular…uh…tolerated series of posts has been my series on the physical exam. If you haven’t done so already, you may want to go back and read the posts to get in the proper mindset (or destroy enough brain cells).
Astute readers will note that doctors are not the only professionals to examine the hand.
Long before we knew anything about carpal tunnel syndrome or the thenar eminence, we had Madam Linda and her cohorts looking at the hand for signs of what the future will bring for the individual that happens to be connected to the hand in question. Just as stars and planets can have a peculiar interest as to whether a person will run into money, the lines on a person’s hand can foreshadow a person’s future. Read more »
*This blog post was originally published at Musings of a Distractible Mind*