You are seeing Mrs. Hudson today, a 60-year-old obese woman with bilateral knee osteoarthritis. Mrs. Hudson describes pain most days and limiting pain at least 2 days per week. She has tried activity modification (walking less) without success. All of the following therapies have been shown to be efficacious in treating osteoarthritis symptoms EXCEPT:
B. Glucocorticoid steroid intra-articular injections
E. Total joint arthroplasty
The answer is C. (Chap. 394) Recent guidelines recommend against the use of glucosamine or chondroitin for OA. Large publicly supported trials have failed to show that, compared with placebo, these compounds relieve pain in persons with disease. Glucocorticoid injections are efficacious in OA, but response is variable, with some patients having little relief of pain, whereas others experience pain relief lasting several months. Glucocorticoid injections are useful to get patients over acute flares of pain and may be especially indicated if the patient has coexistent OA and crystal deposition disease, especially from calcium pyrophosphate dihydrate crystals. Acetaminophen (paracetamol) is the initial analgesic of choice for patients with OA in knees, hips, or hands. For some patients, it is adequate to control symptoms, in which case more toxic drugs such as NSAIDs can be avoided. Doses up to 1 g three times daily can be used. NSAIDs are the most popular drugs to treat osteoarthritic pain. They can be administered either topically or orally. In clinical trials, oral NSAIDs produced approximately 30% greater improvement in pain than high-dose acetaminophen. Ultimately, when the patient with knee or hip OA has failed medical treatment modalities and remains in pain, with limitations of physical function that compromise the quality of life, the patient should be referred for total knee or hip arthroplasty. These are highly efficacious operations that relieve pain and improve function in the vast majority of patients, although rates of success are higher for hip than knee replacement.