Approach to Osteoarthritis Management for the Primary Care Provider

Potential drug-drug interactions in patients presenting with osteoarthritis to community orthopaedic clinics of Abbottabad, Khyber Pakhtunkhwa: A cross-sectional study

OBJECTIVES

Osteoarthritis (OA) causes long-term pain and disorders of lower extremities. Paracetamol is the drug of choice; however, NSAIDs, opioids and steroids are frequently employed in the symptomatic relief of OA. The prescribing of multiple analgesics leads to potential drug-drug interactions (pDDIs). The primary objective of this study was to identify the prevalence and predictors of pDDIs in OA.

MATERIALS AND METHODS

A total of three hundred and eighty-six patients, either newly diagnosed or with a history of OA, were enrolled for this cross-sectional study. Data regarding patients' demographics, clinical characteristics and prescribed medications were recorded from the prescriptions and examined for the pDDIs using Medscape multidrug interaction checker.

RESULTS

Among 386, most patients were females (53.4%). The most prevalent diagnoses were knee OA (39.7%) and unspecified OA (31.3%). Paracetamol and topical NSAIDs were underprescribed whereas an oral NSAID, Diclofenac, was the most frequently used drug in OA. Total of 109 pDDIs were found in 386 prescriptions, of which 63.3% DDIs were categorised as moderate, followed by minor (34.9%) and major (1.8%).

CONCLUSIONS

This study finds a prevalence of DDIs and polypharmacy among the OA patients. Collaborative efforts among healthcare providers, pharmacists, and patients themselves are essential to optimize medication regimens and minimize the polypharmacy including the associated risks as well as DDIs.

Impact of triage by a rheumatologist on appropriateness of referrals from primary to secondary care: a cluster randomized trial

OBJECTIVE

The quality of referrals is often criticized, and the effectiveness of improvement efforts remains uncertain. We assessed the impact of a rheumatologist triaging patients in primary care on the appropriateness of referrals to secondary care, healthcare utilization, and patient experience and outcomes.

METHOD

A cluster randomized controlled trial was conducted with patients experiencing musculoskeletal complaints. Intervention practices deployed an experienced rheumatologist triaging patients through in-person review. Usual care was performed in control practices, where practitioners referred patients based on their own judgement. The primary outcome was the proportion of inflammatory rheumatic diseases (IRDs) diagnosed by rheumatologists in referred patients. Healthcare utilization (iMTA Medical Consumption Questionnaire), quality of life (EuroQol 5 Dimensions), and experience of care (Consumer Quality Index) were determined after 3 months of follow-up. Data were analysed according to the intention-to-treat principle.

RESULTS

In total, 544 participants were included [mean age 51.4 (range 18-87) years; 24% were men]. Of all referred patients, 51% had an IRD in the intervention group versus 21% in the control group (p = 0.035). After 3 months of follow-up, patients from the triage intervention showed lower healthcare utilization (p = 0.006) and higher quality of life (p = 0.011), without a decline in experienced quality of care (p = 0.712), compared to controls.

CONCLUSION

Triage by a rheumatologist in primary care provides appropriate care and adequate experience of care, leading to a higher quality of life. Long-term evidence is needed to assess the value on cost-effectiveness before implementing this strategy nationwide.

Barriers and facilitators for implementation of a digital referral algorithm for inflammatory arthritis - a qualitative assessment in patients and caregivers

Purpose

Difficulty to recognize inflammatory rheumatic diseases (IRD) in a primary care setting leads to late referral to secondary care. An evidence-based digital referral algorithm can support early referral, yet implementation in daily practice only succeeds with support of end users. We aim to understand the context of implementing a digital referral algorithm and explore the potential barriers and facilitators to implementation.

Methods

This qualitative study comprised focus groups and an online survey. Focus groups were performed with patients from outpatient rheumatology clinics. Surveys were sent out to general practitioners and rheumatologists distributed over The Netherlands. The presented digital referral algorithm originates from the JOINT referral study. Thematic analysis was used with inductive and deductive approaches.

Results

In total 26 patients participated distributed over three focus groups, and 215 caregivers (104 rheumatologists, 111 general practitioners) filled out the survey. Both patients and caregivers endorse the need for early referral, and recognize the perceived benefit of the digital algorithm. Potential barriers include the complexity of currently included questions, and the outcome lacking information on what to do with no risk of IRD. In order for implementation to be successful, the inclusivity, accessibility, content and outcome of the algorithm are considered important themes.

Conclusion

Successful implementation of a digital referral algorithm needs a systematic multi-facetted approach, considering the barriers and facilitators for implementation as discussed. Since the majority of identified barriers and facilitators was overlapping between all stakeholders, findings from this study can reliably inform further decision strategies for successful implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01858-w.

Wearable transcutaneous electrical nerve stimulation (actiTENS®) is effective and safe for the treatment of knee osteoarthritis pain: a randomized controlled trial versus weak opioids

INTRODUCTION

Despite their poor tolerance, especially in the elderly, weak opioids (WO) remain commonly prescribed for patients with knee osteoarthritis (KOA). We compared the efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) device with WO for the treatment of moderate-to-severe, nociceptive KOA chronic pain.

METHODS

The study was a non-inferiority, multicentric, prospective, randomized, single-blind, controlled, 2-parallel groups Trial. A total of 110 patients with KOA were included (Kellgren-Lawrence radiographic grade ⩾2; American College of Rheumatology criteria), with chronic moderate-to-severe nociceptive pain (mean 8-day pain intensity (PI) ⩾ 4 on an 11-point numerical rating scale), in failure to non-opioid analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs). Patients with neuropathic pain were excluded. The co-primary endpoints were mean PI at 3 months (M3) and number of potentially treatment-related adverse events (TRAEs). Secondary outcomes included Western Ontario MAC Master University function subscale (range, 0-68), additional pain and quality of life measures, and responder rates.

RESULTS

The non-inferiority of W-TENS was demonstrated in both the per protocol (PP) and intent-to-treat (ITT) populations. At M3, PI in PP population was 3.87 (2.12) compared with 4.66 (2.37) [delta: -0.79 (0.44); 95% CI (-1.65, 0.08)] in W-TENS and WO groups, respectively. A planned superiority analysis showed a significant superiority of W-TENS over WO on PI at M3 (p = 0.0124). The number of TRAEs was significantly lower in the W-TENS group (n = 7) than in the WO group (n = 36) (p < 0.001). Other secondary outcomes also favored W-TENS.

CONCLUSION

W-TENS was more effective and better tolerated than WO in the treatment of chronic nociceptive KOA pain and offers an interesting non-pharmacological analgesic alternative in the management of KOA.Trial Registration: ClinicalTrials.gov: NCT03902340.

The Burden of Pain Associated with Osteoarthritis in the Hip or Knee from the Patient's Perspective: A Multinational Cross-Sectional Study

Introduction

To evaluate, from the patient’s perspective, the burden of pain associated with hip/knee osteoarthritis (OA) in the USA and selected European Union (EU) countries.

Methods

Data were drawn from the 2017 global Adelphi OA Disease Specific Programme™ (DSP). Patients with hip/knee OA were stratified based on pain intensity and the presence/absence of current opioid use. Outcomes included Western Ontario and McMaster Universities Osteoarthritis Index scores, functional limitations, unmet treatment needs, Charlson Comorbidity Index, relevant comorbid conditions, the 5-dimension 5-level EuroQol, and the Work Productivity and Activity Impairment Questionnaire: Specific Health Problem. Bivariate testing compared outcomes using patients with no/mild pain without opioid use as the reference group.

Results

The study population comprised 2170 patients (US: n = 623 [28.7%]; EU: n = 1547 [71.3%]) with knee (54.9%), hip (24.6%), or knee/hip (20.5%) OA. Mean (SD) age was 66.4 (11.2) years. Patients had no/mild pain without opioid use (39.6%), no/mild pain with opioid use (10.2%), moderate/severe pain without opioid use (30.6%), and moderate/severe pain with opioid use (19.7%). Compared with the reference group, patients with moderate/severe pain reported significantly (p < 0.05) higher functional limitations, greater use of ≥ 3 treatments and treatment dissatisfaction, reduced quality of life, and impaired work productivity and activity. The burden was highest with moderate/severe pain with opioid use. Results were generally similar in the US and EU cohorts.

Conclusions

The results from this multinational cross-sectional study indicate that the impact of OA pain is multidimensional, worsened by increasing pain intensity, and may not be adequately addressed by current treatment strategies.

Electronic supplementary material

The online version of this article (10.1007/s12325-020-01445-4) contains supplementary material, which is available to authorized users.

The Effects of Annatto Tocotrienol Supplementation on Cartilage and Subchondral Bone in an Animal Model of Osteoarthritis Induced by Monosodium Iodoacetate

Osteoarthritis is a degenerative joint disease which primarily affects the articular cartilage and subchondral bones. Since there is an underlying localized inflammatory component in the pathogenesis of osteoarthritis, compounds like tocotrienol with anti-inflammatory properties may be able to retard its progression. This study aimed to determine the effects of oral tocotrienol supplementation on the articular cartilage and subchondral bone in a rat model of osteoarthritis induced by monosodium iodoacetate (MIA). Thirty male Sprague-Dawley rats (three-month-old) were randomized into five groups. Four groups were induced with osteoarthritis (single injection of MIA at week 0) and another served as the sham group. Three of the four groups with osteoarthritis were supplemented with annatto tocotrienol at 50, 100 and 150 mg/kg/day orally for five weeks. At week 5, all rats were sacrificed, and their tibial-femoral joints were harvested for analysis. The results indicated that the groups which received annatto tocotrienol at 100 and 150 mg/kg/day had lower histological scores and cartilage remodeling markers. Annatto tocotrienol at 150 mg/kg/day significantly lowered the osteocalcin levels and osteoclast surface of subchondral bone. In conclusion, annatto tocotrienol may potentially retard the progression of osteoarthritis. Future studies to confirm its mechanism of joint protection should be performed.

Comparative short-term effectiveness of ibuprofen gel and cream phonophoresis in patients with knee osteoarthritis

The objective of the present study was to compare the effectiveness of gel and cream ibuprofen phonophoresis in patients with knee osteoarthritis. A single-blinded, randomized, comparative design was applied. Patients diagnosed with knee osteoarthritis according to the American College of Rheumatology criteria were included in the study. After obtaining written informed consent, patients were randomized into ibuprofen gel and cream phonophoresis groups. Each patient was treated five sessions per week for 2 weeks (ten sessions). Main outcome measures were 100 mm visual analogue scale (VAS) for pain and the disease-specific questionnaire; Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Sixty-one knee osteoarthritis patients with a mean age of 57.9 ± 9.7 years were included in the study. Baseline VAS and WOMAC scores were similar between gel (n = 30) and cream (n = 31) phonophoresis groups (p > 0.05 for both). Following the treatment, both groups showed improvement compared to baseline measures including VAS pain and WOMAC scores. In the gel phonophoresis group, the improvement in VAS score was higher than that observed in the cream phonophoresis group (p < 0.001). Similarly, the improvement in WOMAC total score was also higher in the gel phonophoresis group (p < 0.001). Ibuprofen phonophoresis is clinically effective in patients with knee osteoarthritis. Phonophoresis using the gel form of ibuprofen is associated with more clinical improvement than that using the cream form of the same molecule.