While some types of arthritis have benefited from breakthroughs in disease-modifying drugs, physicians rely on a more limited set of options to treat osteoarthritis. But the optimal regimen, which emphasizes nonpharmacological measures to start, can still help patients achieve notable relief, according to osteoarthritis experts.
Even relatively small changes in exercise and weight loss may ease pain for the roughly 33 million Americans with various types of osteoarthritis, which most commonly impacts the knee, they said. To achieve success, physicians should strive to tap the expertise of physical therapists, registered dietitians, and other clinicians, as well as assume the long view.
“I think the biggest challenge is overcoming the notion that there's nothing that can be done,” said Sharon L. Kolasinski, MD, FACP, a rheumatologist and professor of clinical medicine at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, as well as lead author of the most recent osteoarthritis guideline, published Jan. 6, 2020, in Arthritis & Rheumatology. “It both takes time and creativity and patience and a menu of strategies to get people to exercise and continue to participate in exercise and certainly to lose weight. They're not easy things to incorporate into your daily life, especially at the point where you're in pain from arthritis.”
A demographic analysis published in 2016 in Arthritis Care & Research found that of roughly 14 million Americans who had symptomatic knee osteoarthritis, slightly more than half had severe cases. Nearly 2 million adults diagnosed with the disease in this analysis were younger than age 45 years. Non-Hispanic White patients comprised roughly three-fourths of cases; among other groups, the diagnosis was more common in non-Hispanic Black patients and Hispanic patients.
The recent osteoarthritis guideline, published by the American College of Rheumatology (ACR) and the Arthritis Foundation (AF), is one of a cadre of available guidelines issued by medical groups in the U.S. and elsewhere. A JAMA review published Feb. 9, which includes a chart that summarizes knee and hip osteoarthritis recommendations from four groups, finds that they all lean heavily on nonpharmacological approaches to ideally reduce the need for nonsteroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, and joint replacement, though some patients may still require surgery.
Encouraging research avenues are being pursued, including potential new classes of drugs and a National Institutes of Health study that is recruiting patients to look at various combinations of nonopioid treatments, said Marc C. Hochberg, MD, MPH, MACP, division head of rheumatology and clinical immunology at the University of Maryland School of Medicine in Baltimore. In the meantime, he suggests that primary care physicians incorporate a team-based approach with other clinicians when feasible. Plus, maintain a positive mindset, Dr. Hochberg said, noting that older physicians may have been taught that osteoarthritis is a degenerative disease.
“They think that it's something you just get with aging and you have to learn to live with it,” he said. “And it's going to necessarily progress. And that is a defeatist attitude to provide to the patient.”
Educate patients that even a small amount of weight loss, such as 5%, can ease knee joint pain, Dr. Kolasinski said. “We should not make unattainable goals for patients,” she said. “Even a little weight loss can be beneficial.”
At this stage, referring patients to a registered dietitian can be quite helpful, Dr. Hochberg said. Not only does the dietitian have more time to work with the patient to design a weight management plan but they also can suggest steps to address other medical conditions, such as strategies to reduce sodium in those patients with high blood pressure. This is important because so many patients are affected by multiple chronic conditions at once, such as hypertension and arthritis. Addressing a risk factor for one condition is then beneficial for others (obesity, heart disease, diabetes) as well, he added.
With each pound of weight shed, there is a fourfold reduction in the force exerted on the knees with every step, according to a 2005 study published in Arthritis & Rheumatology. More recent research by one of that study's authors, Stephen Messier, PhD, found that as weight loss increases, so does the impact on knee pain and related functioning.
“If you get someone to lose 10% of their body weight over a long period of time, 12 months to 18 months, then they're going to feel like different people,” said Dr. Messier, a professor of health and exercise science at Wake Forest University in Winston-Salem, N.C.
Dr. Messier led a randomized study, published in JAMA in 2013, which found that combining exercise with a weight loss goal of at least 10% reaped even better results in overweight or obese adults with symptomatic knee osteoarthritis. After 18 months, the adults who were in the group that combined both interventions reported less knee pain and better function, including faster walking speed, than those who pursued weight loss or exercise only.
The ACR/AF guideline did not find any specific hierarchy in existing research indicating that certain types of exercise help patients more, saying that choice should be driven by individual preference. A referral to a physical therapist can help sort out the best regimen, Dr. Kolasinski said. But patients, she said, should not be permitted to use their knee pain as an excuse for not getting active. “All of the studies that were done with exercise in osteoarthritis were done with participants who were in pain.”
This heightened focus on maximizing physical activity represents a sea change from even a decade ago, said Nancy Lane, MD, distinguished professor of medicine and rheumatology at UC Davis School of Medicine in Sacramento, Calif.
“The good news is, I think, that we have liberated the arthritic patient to do everything they can within the confines of their pain and this disease,” Dr. Lane said. “If you think back 10 years ago, for people with osteoarthritis of the knee or the hip, we wrote a prescription for them to be couch potatoes. Because if you did anything and your joint hurt, then don't do it.”
But Dr. Messier's research highlights the gap between study-driven exercise and real-world activity. In his 2013 JAMA study, participants were directed to complete an exercise regimen totaling 180 minutes weekly with aerobic exercise and strength training. Many adults with knee osteoarthritis, however, fall short of even the federal government's lower benchmark of at least 150 minutes of activity weekly. One study, which tracked movement based on participants wearing an accelerometer and not on self-reporting, found that only 12.9% of men and 7.7% of women with knee osteoarthritis met that goal, according to the findings, published in Arthritis & Rheumatology in 2011.
Traditionally, strength training has been recommended for osteoarthritis patients, including in the most recent ACR/AF guideline, based on the theory that boosting muscle strength would increase the shock absorption and reduce the load on the joint, Dr. Messier said.
But a recent study that he led, which looked at lifting heavy weights versus lower-intensity training in adults ages 50 years and older with knee osteoarthritis, found that both groups reported a similar reduction in pain of about 30% over 18 months, according to the findings, published Feb. 16 in JAMA. Lifting heavier weights does not appear to be more beneficial, though exercise in general in this population does have a small to moderate effect that's clinically important, Dr. Messier said.
Still, he also noted that the control group that only completed educational sessions, including nutrition and medication management as well as some upper body stretching exercises, also described a similar 30% reduction in knee pain to the two strength-training groups. One possibility is that the benefits of exercise in older adults may be more related to the heightened attention paid to the group as part of the regimen, he said.
Patients trying to avoid or reduce medications can try some other strategies, according to the latest ACR/AF guideline. Tai chi is strongly recommended for patients with knee or hip osteoarthritis. Yoga is conditionally recommended for the knee. Cognitive behavioral therapy is conditionally recommended for all joints, which makes sense given the potential disabling impact of osteoarthritis, Dr. Kolasinski said.
“This means that it contributes to a lot of stress, a lot of lifestyle limitations, and a lot of changes in role and the way patients perceive themselves,” she said, all of which can frame the perception of pain and open up a role for the therapeutic pain management approach.
One of the medication changes in the latest ACR/AF guideline has been a move to deemphasize the use of acetaminophen, given its negligible benefit and the potential risk for drug-induced liver injury, said Dr. Hochberg, a guideline coauthor. For patients with knee osteoarthritis, trying a topical NSAID first is a good start, ideally for two to four weeks to see if it does help, he said. The topical medication is a better choice for the knee than the hip, given how deeply the hip joint is located, the guideline authors noted.
Oral NSAIDs continue to be the mainstay of pharmacological treatment, but doses should be kept as low as possible, according to the guideline. Older patients are more likely to have other conditions, such as reduced kidney function, that contraindicate the use of the drugs, Dr. Hochberg said.
“There's a conundrum here,” he said. “For patients who are either intolerant of, have contraindications to, or haven't responded to oral NSAIDs, there aren't that many other oral agents to use.”
One option, conditionally recommended in the guideline, is duloxetine, which the authors noted has been studied primarily in the knee but “may plausibly be expected to be similar” for hip or hand osteoarthritis. Physicians should watch out for potential interactions with other drugs, such as other antidepressants or anticoagulants, Dr. Hochberg said.
Tramadol is conditionally recommended in the ACR/AF guideline if an opioid is being considered; nontramadol opioids are conditionally recommended against. The guideline also recommends against some dietary supplements to varying degrees in all forms of osteoarthritis, including conditionally against fish oil and vitamin D and strongly against glucosamine.
Physicians should check in with patients to find out if they are taking any dietary supplements or have tried to medicate their pain with cannabis or cannabidiol (CBD), Dr. Lane said. For some patients, cannabis can be helpful in reducing joint pain, with the caveats that they are strongly advised to avoid certain activities, such as driving, as they would if taking opioid analgesics, she said. “If they need the cannabis, the medical marijuana, and they use it responsibly, I think it's an alternative,” she said.
Above all, she stressed, “I think it's really important for primary care physicians and internists to understand that at the point that patients are taking opioid analgesics or medical marijuana, that's the time to really evaluate and understand why they're not seeking a joint replacement.”
Physicians should refer patients to a surgeon for a possible knee replacement once the pain becomes too much to tolerate or it's having too much of an impact on their daily life, Dr. Kolasinski said.
“Often, from a practical standpoint, that is when patients are having night pain, the pain wakes them up in the middle of the night,” she said. “Or they have rest pain, where they've got a degree of pain even when sitting still.”
By not delaying the referral to a surgeon, physicians maximize the likelihood that patients can recover quickly and return to their preferred exercise and other daily activities, Dr. Lane said. “You want to get them in,” she said. “The joint is not going to regenerate. The muscle around the joint deteriorates. You want to get a joint replacement when they have a chance to have a lot of resilience.”
Meanwhile, Dr. Lane and others cited hopeful signs of emerging therapies that may one day target the underpinnings of the disease. For instance, a recently published exploratory analysis looked at the drug canakinumab, which had been initially studied in heart attack patients with elevated levels of the inflammatory marker C-reactive protein. The industry-funded study identified a potential osteoarthritis benefit, as patients taking the drug were less likely to get a knee or joint replacement during a median follow-up of nearly four years, according to the results, published Oct. 6, 2020, in Annals of Internal Medicine.
More research will be needed, but that anti-inflammatory insight opens the door to further drug development, said Dr. Lane, one of the authors of the accompanying editorial. “Finally, we can truly say that [osteoarthritis] is in many people a low-grade inflammatory condition and that intervening can make a difference,” she said. “Now we have to find safe and effective [pharmaceutical] interventions.”
Other drug research is in clinical trials, such as nerve growth factor inhibitors that are being looked at for pain relief, Dr. Kolasinski said. Researchers also are looking at ways to regenerate cartilage but have not yet been able to demonstrate clinically meaningful improvements, she said.
But she remains hopeful. “The history of osteoarthritis treatment has been pain management, how to approach the pain that the arthritis gives you,” she said. “And we are really looking at a future where we can actually change the pathophysiology of the disease.”