Therapeutic Target
- Relief of symptoms
Therapy recommendations
- In general, the analgesic/pain reliever paracetamol (best tolerated) is recommended for nonactive osteoarthritis. Caution. No effect of paracetamol in patients with gonarthrosis (knee joint osteoarthritis). According to a meta-analysis, paracetamol is hardly effective in gonarthrosis and coxarthrosis.
- In activated osteoarthritis (abraded cartilage or bone inflamed): non-steroidal anti-inflammatory drugs (NSAIDs), eg diclofenac or agents from the group of COX-2 inhibitors, eg celecoxib, celebrex or etoricoxib, Arcoxia [no long-term therapy!].
- In terms of pain and function, in patients with gonarthrosis and coxarthrosis (knee and hip osteoarthritis), diclofenac – and, with slight reductions – etoricoxib work best. Note: No diclofenac in cardiovascular risk! This affects patients with heart failure (cardiac insufficiency) NYHA classes II to IV, coronary artery disease (CAD, coronary artery disease), peripheral arterial disease (PAVD) or cerebrovascular disease.
- Glucocorticoids, if appropriate; the effect of intra-articular injection (“into the joint cavity”) is controversial (EULAR guideline: 1b; OARSI guideline: appropriate; AAOS guideline: not appropriate), but may be administered if inflammation cannot be controlled otherwise.
Further notes
- Intravenous administration (administration) does not provide advantages over oral administration.
- Continuous therapy should not be used.
- Different NSAIDs should not be combined!
- Alternative therapy for high cardiovascular/gastrointestinal (affecting the cardiovascular system and gastrointestinal tract) risk → conventional NSAIDs + low-dose acetylsalicylic acid (ASA) + proton pump inhibitors (PPI; acid blockers) (recommendation of the Drug Commission of the German Medical Association).
- In patients with gonarthrosis, aspirin at low doses (<300 mg) resulted in reduced medial tibial cartilage loss over a course of more than 2 years.
- Findings from a systematic review and meta-analysis indicate that pain sensitization is present in patients with gonarthrosis and may be associated with symptom severity.
- Caveat. According to a cohort study, 1-year mortality rates were significantly increased after short- to medium-term tramadol use as an analgesic compared with NSAIDs (naproxen, diclofenac, celecoxib, and etoricoxib) in patients with osteoarthritis. Death rates under codeine were similar to those under tramadol in a head-to-head comparison (34.6 and 32.2/1,000 person-years, respectively).
Glucocorticoids
- Mode of action: Glucocorticoids have an antiphlogistic (anti-inflammatory) and anti-edematous (decongestant) effect.
- The effect in intra-articular injection (“injection into the joint cavity”) is controversially assessed (EULAR guideline: 1b; OARSI guideline: suitable; AAOS guideline: not suitable), but can be administered in cases of inflammation that cannot be controlled otherwise.
- In a study involving a total of 100 patients with manifest gonarthrosis, half of each patient was treated by intra-articular injection with 40 mg/ml methylprednisolone dissolved in 4 ml lidocaine hydrochloride (10 mg/ml), and the other half received only a mixture of saline and lidocaine in a 4: 1 ratio. Pain was then assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS). There was no significant difference between the verum group and the placebo group.
- In a study of 140 patients with gonarthrosis, in which a 1-ml injection of 40 mg/ml triamcinolone was regularly applied intra-articularly for two years, there was no improvement in gonarthrosis pain compared with saline injections, but there was significantly more cartilage loss in the knee joint. Evidence of cartilage loss was obtained by knee MRI.
- Note: Intra-articular corticoid injection (administration of glucocorticoids into the joint cavity) is likely to cause joint damage. This is suggested by the following radiologic findings:
- Rapid narrowing of the joint space (rapid progressive osteoarthrits, RPOA type 1) occurred in 6% of all participants.
- In about one percent, so-called SIF (subchondral insufficiency fractures) were detectable); it is assumed that this is the result of a relative overload with structurally or density reduced bone
- Other patients showed osteonecrosis (ON; “bone death”) or joint destruction with demonstrable bone loss (RPOA type 2).
Here, the authors discuss the following issue: they state that they do not know whether the observed damage was already proceeding at the time of injection or whether it is a consequence or complication of corticosteroid treatment. It is possible that the injections may have prevented pre-existing damage from healing?! Note: This is an observational study with a small number of cases.
Therapy attempts without success
- Zoledronic acid (bisphosphonate): can not slow the loss of articular cartilage and bone mass, nor relieve the symptoms of patients.
Supplements (dietary supplements; vital substances)
Usually, drugs from the above groups are taken in combination with chondroprotectants/cartilage-protecting agents (e.g., glucosamine sulfate, chondroitin sulfate) to inhibit cartilage-degrading substances and provide relief or improvement of pain. In a multicenter intervention study with 606 gonarthrosis patients, it was demonstrated that the effect of glucosamine and chondroitin for the therapy of gonarthrosis showed identical effects as a drug treatment with the selective COX-2 inhibitor celecoxib. Both forms of therapy reduced the pain index of gonarthrosis patients by approximately 50%. The decrease in joint swelling and joint effusion also decreased equally in both groups. For more information on chondroprotectants, see the following chapter. Note: Chondroprotectants should preferably be taken in combination with other bone-active vital substances, such as vitamins (C, D, E, K) and, if necessary, omega-3 fatty acids (docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)).
