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Managing Osteoarthritis-associated Pain
Declaration of sponsorship Pfizer and Lilly

Burden of OA-associated pain

Declaration of sponsorship Pfizer and Lilly
Read time: 60 mins
Last updated:4th Nov 2022
Published:10th Nov 2020
  • What are the problems with traditional methods for assessing OA pain?
  • Why is current pain management often either ineffective or inappropriate?
  • Can over-prescription of opioids and subsequent dependence issues be avoided?
  • Meet ‘Marie’, our patient with knee OA and see how OA affects her daily life

Osteoarthritis-associated pain

Pain associated with osteoarthritis is significant and requires an alternative management approach

Osteoarthritis (OA) is the most common form of arthritis, estimated to affect 302 million people worldwide1. The knees, hips and hands are the most commonly affected joints; knee and hip osteoarthritis rank highly as global causes of disability (eleventh highest) and chronic pain among older adults1-3. OA may also lead to increased risk of all-cause mortality and the incidence of OA continues to rise due to both the ageing population and increased prevalence of obesity4.

OA is a heterogeneous condition involving the whole joint. Pathology includes structural alteration of cartilage, subchondral bone, ligaments, capsule, periarticular muscles and synovial inflammation which leads to pain, stiffness, swelling and loss of function1,5.

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As OA is a progressive disorder with varying degrees of severity it requires long-term management over the disease course. As there is no disease-modifying treatment for OA, treatment is largely based on symptom relief. Reducing the pain associated with OA can reduce the impact of OA on the patient's mobility and quality of life4. Pain is therefore the major driver of clinical decision making in OA6.

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Let’s meet our patient ‘Marie’. How does knee osteoarthritis affect her daily life?

Note: this is a theoretical case for educational purposes only. Marie has had osteoarthritis (OA) for a number of years and so we review her treatment and comment on how she might have been treated differently using the current guideline recommendations. At the bottom of the page, you will have the opportunity to complete a short quiz based on this case study.

Marie_1.pngInitial clinical presentation

  • Female, 55 years old, obese (BMI 34 kg/m2)
  • 3-year history of progressively worsening pain in both knees
  • Knees stiff for about 20 minutes first thing in the morning and for a few minutes after getting up from a chair during the day
  • Difficulty walking >30 minutes because of pain and swelling (limits recreational walking with friends)
  • Symptoms exacerbated by kneeling, squatting or descending stairs (limits gardening and housework)
  • Sitting, resting and reclining relieve pain, but becomes stiff if in one position for too long
  • Symptoms worse on humid or cold days

Her increasing pain led Marie to see her doctor who referred her to a specialist for evaluation.

Physical examination

Physical examination of the lower extremities revealed:

  • Mildly antalgic gait (limp to avoid pain) and passive range of motion of both knees indicated palpable crepitus (grating or crunching)
  • Unable to flex or extend knees completely:
    • maximum flexion <120° ( normal maximum flexion is 140–150°, physically active OA patient commonly has a maximum flexion <130°)
    • 8° loss of extension (<10° loss in severe OA)
    • patellar facet tenderness, tenderness over the joint line and patellofemoral crepitus (common in patients with knee OA), moderate warmth and soft-tissue swelling, patellar tilt and moderately severe decreased patellar glide (medially and laterally)
    • medial pseudolaxity (symmetric instability)
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Linear pain scales overused in osteoarthritis

Traditional linear pain assessment scales are sometimes overused in osteoarthritis and may not be fit-for-purpose in assessing patient QoL in the real world

Accurate pain assessment is the foundation of optimal management7. However, because pain is highly subjective, assessing severity can be difficult. Indeed, healthcare professionals (HCPs) and patients frequently differ in their perception of pain severity associated with a condition or extent of tissue damage8. In a study comparing patient–physician discordance in global assessment of patients with osteoarthritis  (OA) (n = 243) versus patients with rheumatoid arthritis (RA) (n = 216), patients with OA were more likely to be discordant with their rheumatologists than patients with RA with the most important explanatory variable for discordance being higher levels of pain9.

Traditionally visual analogue scales (VAS) are used to assess pain. Patients are asked to place a line perpendicular to the VAS line at the point that represents their pain intensity. Using a ruler, the score is determined by measuring the distance (mm) on the 10 cm line between the ‘no pain’ anchor and the ‘pain as bad as it could be’ extreme10. A score of more than 30 mm on the 10 cm scale suggests moderate pain11 (Figure 1).

PFI_Osteo_Fig1.1.png

Figure 1. Interpreting the visual analogue pain score (Adapted11,12)

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Current osteoarthritis treatments often ineffective

Current osteoarthritis pain treatments are often ineffective, which may lead to treatment escalation and use of controlled drugs associated with more serious side effects

An observational study in patients with knee osteoarthritis (OA) suggests that inadequate pain relief (IPR) is highly prevalent. Following a year of physician-prescribed treatment, 54% of patients reported IPR (moderate-to-severe pain)13. This suggests that currently prescribed pain treatments for knee OA are not meeting the needs of the majority of patients13.

Current osteoarthritis treatments

Figure 2 shows the 2019 Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) treatment algorithm for knee OA, which recommends a combination of non-pharmacological and pharmacological treatment approaches4. There are similar recommendations for hand, knee and hip OA1, and it is notable that the majority of treatments are only weakly recommended.

PFI_Osteo_Fig1.2.png

Figure 2. ESCEO stepwise treatment algorithm for knee osteoarthritis (Adapted4). COX-2, cyclooxygenase-2; CS, chondroitin sulphate; CV, cardiovascular; GI, gastrointestinal; GS, glucosamine sulphate; IA, intra-articular; NSAID, non-steroidal anti-inflammatory drug; PPI, proton pump inhibitor; SYSADOA, symptomatic slow-acting drugs in osteoarthritis; OA, osteoarthritis.

Pharmacological treatment approaches for osteoarthritis pain

Paracetamol

The ESCEO working group gives a weak recommendation for the use of paracetamol and that it should not be used on a regular basis as long-term background pharmacological therapy for the management of knee OA4. This is based on questionable efficacy (minimal analgesic effect size of 0.14 [95% confidence interval 0.05–0.22], essentially no detectable clinical effect and no significant effect on stiffness and physical function in patients with knee OA) and confirmed safety issues (gastrointestinal, cardiovascular, hepatic and renal side effects)4.

ESCEO does give a weak recommendation that paracetamol (≤3 g/day) may be used as short-term rescue analgesia only, when given in addition to symptomatic slow-acting drugs for OA (SYSADOAs, glucosamine, chondroitin, diacerein and avocado soybean unsaponifiables)4 .

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Opioid addiction avoidable

Opioids offer only small benefits in terms of pain and function in osteoarthritis (OA) and do not improve quality of life or depression16

There are a number of consensus and position statements that recommend against the use of opioid pain medication for the treatment of OA (American Association of Orthopaedic Surgeons [AAOS]17; American Association of Hand and Knee Surgeons [AAHKS]18). Despite these recommendations, nearly 27% of patients with OA still receive opioids and benzodiazepines, with about 36% of such individuals demonstrating at least one risk factor for prescription misuse (the most prevalent being ‘early refill’ and a history of receiving ≥3 prescriptions in the previous month), according to data from a large US health care system19.

Opioid overuse in OA has also been reported in Europe. In a 12-month study in 751,579 residents in Sweden, 23.7% patients with OA were prescribed opioids [95% confidence intervals 23.3–24.2], which was twofold higher than for individuals without knee or hip OA. Similarly, patients with OA were more likely to have an incident opioid dispensation, particularly for strong opioids (incidence rate ratio: 2.6 [95% confidence interval 2.5-2.7])20.

These studies highlight that patients with knee and hip OA constitute a group of patients with a worryingly high use of opioids despite recent international concerns about the devastating potential for chemical dependency posed by opioid medications3.

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Socioeconomic burden of osteoarthritis

The socioeconomic burden associated with osteoarthritis pain is significant and underestimated

What is the economic burden of osteoarthritis (OA)? Given its high prevalence, OA incurs substantial health and societal costs, both directly (clinician visits, treatments, surgery) and indirectly (impaired work productivity and early retirement)3.

The costs associated with OA can be particularly significant for the elderly, who face potential loss of independence and a requirement for help with activities of daily living. While estimating costs is difficult, the US Bone and Joint Initiative (USBJI) has highlighted the enormous economic impact of OA in their 2018 Burden of Musculoskeletal Diseases report21:

  • In 2008–14, per-person medical costs attributed to OA averaged $11,052 per-year
  • In 2008–14, annual all-cause costs (both direct and indirect) attributed to OA and allied disorders averaged $486.4 billion nationally
  • In 2013, there were 20.78 million ambulatory care visits and ~2.95 million inpatient hospitalisations for patients with OA and associated disorders

In Europe a 2013 review estimated that22:

  • the average total annual cost of OA per patient in Europe ranged from €1,330 to €10,452
  • when considering only direct medical costs, the annual cost of OA ranged from €534 to €1,788
  • in active patients, the indirect costs were much higher than the direct costs

The costs associated with osteoarthritis can be particularly significant for the elderly, who face potential loss of independence and a requirement for daily help with living activities. While estimating costs is difficult, the United States Bone and Joint Initiative (USBJI) has highlighted the enormous economic impact of OA in their 2018 Burden of Musculoskeletal Diseases report21:

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References

  1. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72(2):220–233.
  2. Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee osteoarthritis: Estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(7):1323–1330.
  3. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthr Cartil. 2019;27(11):1578–1589.
  4. Bruyere O, Honvo G, Veronese N, Arden NK, Branco J, Curtis EM, et al. An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Semin Arthritis Rheum. 2019;49(3):337–350.
  5. Brandt KD, Radin EL, Dieppe PA, Van De Putte L. Yet more evidence that osteoarthritis is not a cartilage disease. Annals of the Rheumatic Diseases. 2006;65(10):1261–1264.
  6. Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. The Lancet. 2019;393(10182):1745–1759.
  7. Fink R. Pain assessment: The cornerstone to optimal pain management. Proc (Bayl Univ Med Cent). 2000;13(3):236–239.
  8. Studenic P, Radner H, Smolen JS, Aletaha D. Discrepancies between patients and physicians in their perceptions of rheumatoid arthritis disease activity. Arthritis Rheum. 2012;64(9):2814–2823.
  9. Castrejon I, Shakoor N, Chua JR, Block JA. Discordance of global assessment by patients and physicians is higher in osteoarthritis than in rheumatoid arthritis: a cross-sectional study from routine care. Rheumatol Int. 2018;38(11):2137–2145.
  10. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form‐36 Bodily Pain Scale (SF. Arthritis Care Res (Hoboken). 2011;63(S11):S240–S252.
  11. Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: What is moderate pain in millimetres? Pain. 1997;72(1–2):95–97.
  12. Moore RA, Straube S, Aldington D. Pain measures and cut-offs - ‘no worse than mild pain’ as a simple, universal outcome. Anaesthesia. 2013;68(4):400–412.
  13. Conaghan PG, Peloso PM, Everett S V, Rajagopalan S, Black CM, Mavros P, et al. Inadequate pain relief and large functional loss among patients with knee osteoarthritis: evidence from a prospective multinational longitudinal study of osteoarthritis real-world therapies. Rheumatology. 2015;54(2):270–277.
  14. Mora JC, Przkora R, Cruz-Almeida Y. Knee osteoarthritis: pathophysiology and current treatment modalities. J Pain Res. 2018;11–2189.
  15. da Costa BR, Nüesch E, Kasteler R, Husni E, Welch V, Rutjes AWS, et al. Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane database Syst Rev. 2014;(9):CD003115–CD003115.
  16. Osani M, Lohmander S, Bannuru R. Is there any role for opioids in the management of OA? ACR Meeting Abstracts. 2019;910.
  17. AAOS. Management of osteoarthritis of the hip companion consensus statements. Available at: https://www.aaos.org/globalassets/quality-and-practice-resources/osteoarthritis-of-the-hip/management-of-osteoarthritis-of-the-hip-companion-consensus-statements_3.13.17.pdf. Accessed 1 April 2020.
  18. AAHKS. Opioids. Available at: http://www.aahks.org/position-statements/opioid-use-for-the-treatment-of-osteoarthritis-of-the-hip-and-knee/. Accessed 20 March 2020.
  19. Alamanda VK, Wally MK, Seymour RB, Springer BD, Hsu JR, Beuhler M, et al. Opioid and benzodiazepine prescriptions for osteoarthritis remain prevalent. Arthritis Care Res (Hoboken). 2019;acr.23933.
  20. Thorlund JB, Turkiewicz A, Prieto-Alhambra D, Englund M. Opioid use in knee or hip osteoarthritis: a region-wide population-based cohort study. Osteoarthr Cartil. 2019;27(6):871–877.
  21. USBJI. Osteoarthritis. BMUS: The Burden of Musculoskeletal Diseases in the United States. Available from: https://www.boneandjointburden.org/fourth-edition/iiib10/osteoarthritis. Accessed 2 April 2020.
  22. Hiligsmann M, Reginster J-Y. The economic weight of osteoarthritis in Europe. Medicographia. 2013;35:197–202.
  23. Leardini G, Salaffi F, Caporali R, Canesi B, Rovati L, Montanelli R. Direct and indirect costs of osteoarthritis of the knee. Clin Exp Rheumatol. 2004;22(6):699–706.
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