Knee osteoarthritis

The efficacy of intra-articular triamcinolone acetonide 10 mg vs. 40 mg in patients with knee osteoarthritis: a non-inferiority, randomized, controlled, double-blind, multicenter study.

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BACKGROUND: Intra-articular (IA) corticosteroid injection is recommended in refractory knee osteoarthritis patients. However, 40-mg of triamcinolone IA every 3 months for 2 years reduces cartilage volume as compared to saline IA.

OBJECTIVE: To determine the non-inferiority of 10-mg versus 40-mg of triamcinolone acetonide (TA) for treatment of pain in symptomatic knee osteoarthritis at week 12.

METHODS: This was a double-blind, randomized, controlled trial conducted in 84 symptomatic knee osteoarthritis patients. The 10-mg or 40-mg of TA were 1:1 randomized and injected to the affected knees. The primary outcome was the 12-week difference from baseline in pain VAS, with a pre-specified lower margin for non-inferiority of 10 mm. The measuring instruments used were: Visual analog scale (VAS: 0-10), modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol Group 5 Dimensions (EQ5D), Knee Injuries and Osteoarthritis Outcome Score (KOOS) questionnaire, chair standing test and 20-m walking time at baseline, at week 4, and week 12 after randomization. Adverse events were recorded.

RESULTS: Baseline characteristics were similar between two groups. The mean differences of pain VAS (95% confidence interval: CI) between the two groups at baseline and week 12 were 0.8 (-0.8, 2.4) with p of 0.002 for non-inferiority. There were no differences in pain reduction and quality of life improvement between 10-mg and 40-mg groups. The mean differences (95%CI) of WOMAC, KOOS pain, EQ5D and KOOS quality of life between baseline and week 12 were 0.4 (-1.1, 1.9). -8.7 (-21.3, 3.9), 1.3(-7.1, 9.6) and 1.8 (-11.5, 15.0), respectively. There were significant improvements in pain and quality of life between baseline and week 12 in both groups.

CONCLUSION: The 10 mg of TA is non-inferior to 40 mg TA in improving pain in patients with symptomatic knee OA. Both 10 mg and 40 mg of TA significantly improved pain and quality of life in patients with symptomatic knee OA.

Tramadol for Hip or Knee Osteoarthritis?

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A meta-analysis suggests minimal benefit and substantial adverse effects.

In a guideline from the American College of Rheumatology, the opioid tramadol is “conditionally recommended” for patients with hip or knee osteoarthritis (OA), when other treatments are ineffective or contraindicated (Arthritis Rheumatol 2020; 72:220. opens in new tab). In this meta-analysis, researchers examined the efficacy of tramadol in six placebo-controlled, randomized trials that involved 3600 patients with hip or knee OA. Doses were 100, 200, or 300 mg daily, and trial durations were mostly 12 weeks.

All doses of tramadol were statistically better than placebo for pain relief, but the average difference from placebo (even for the 300-mg dose) was equivalent to less than 1 point on a 10-point scale and was not considered to be clinically important. Only the 300-mg dose resulted in functional improvement compared with placebo, but the effect was very small. Gastrointestinal side effects and central nervous system side effects were substantially more common with all doses of tramadol than with placebo.

Comment

These average outcomes in clinical trials don’t preclude the possibility that, in an occasional patient, tramadol will provide clinically meaningful pain relief with no adverse effects. But overall, the data don’t support daily tramadol for extended treatment of hip or knee osteoarthritis. Remember that tramadol is not only an opioid-receptor agonist, but also an inhibitor of serotonin and norepinephrine reuptake; in addition to its predictable opioid-related adverse effects, serotonin syndrome and seizures have been reported with this drug.

Source: NEJM

What are the drugs used for the treatment of knee osteoarthritis?

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Osteoarthritis (OA) is a musculoskeletal progressive disease, with an affected knee joint. The pharmacological treatment of knee osteoarthritis is considered symptomatic therapy, which often secures the retainment of mobility of the patient. The pharmacological interventions of OA are suggested by recent guidelines, such as AAOS (American Academy of Orthopedic Surgeons), and ACR/AF (American College of Rheumatology/Arthritis Foundation).

DrugDosage
Acetaminophen (Paracetamol)Maximum 4g/day
Non-steroidal anti-inflammatory drugs (NSAIDs)
Ibuprofen low dose (400 mg thrice daily) or medium dose (600 mg thrice daily), max 3200 mg daily
Naproxenlow dose (250 mg thrice daily) or medium dose (500 mg twice daily), with a maximum of 1250 mg daily.
Diclofenac50 mg twice daily or 75 mg twice daily, with a maximum of 200 mg daily
Celecoxib200 mg once daily of low dose to maximum dose of 200 mg twice daily
Gastroprotective agents
Misoprostol Standard dose 200 μg once daily
Proton pump inhibitor
Omeprazole 40 mg once daily
Opioid analgesics
Codeine10 mg twice daily
Fentanyl patch25 μg 
Tramadol50 to 100 mg every 4 to 6 hours
Oxycodone20 mg daily
Topical NSAIDs
Topical Capsaicin
Glucosamine and Chondroitin sulfate
Intraarticular glucocorticoids
Methylprednisolone acetateTriamcinolone acetonide 20 to 40 mg; once in every 3 months
Intraarticular Hyaluronic acid
Duloxetine
Bisphosphonates
Hydroxychloroquine
Methotrexate
Intraarticular Botullinum toxin.[1]

Suggested approach to the treatment of OA as per the American Academy of Physicians:

First-line pharmacotherapy: Full-dose of Acetaminophen, topical therapies.

Second-line treatments: Oral NSAIDs

Third-line treatments: Tramadol or Duloxetine 

Fourth-line treatments: Opiates (50 mg of Hydrocodone or ≤ 30 mg of Oxycodone per day)

Multiple vs single hyaluronic acid injection: which is more effective for knee osteoarthritis?

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https://speciality.medicaldialogues.in/multiple-vs-single-hyaluronic-acid-injection-which-is-more-effective-for-knee-osteoarthritis/

If You Take Tylenol For Joint Pain, You Need To Read This

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tylenol
If the pain is bad enough to send you rummaging through your medicine cabinet, you’re probably on the hunt for something that works—and fast. But a new study suggests one of the most common over-the-counter pain meds may not be the cure-all you once thought.

According to new research, published in the BMJ, acetaminophen—known to most of us as Tylenol—isn’t all that effective at relieving pain from osteoarthritis, the most common form of arthritis.

Because acetaminophen is one of the most popular tools for treating pain, study author Gustavo Machado, a PhD student at the George Institute for Global Health and the University of Sydney medical school in Australia, says he and his co-authors wanted to assess its safety and efficacy. And their findings are not too promising: “Our results revealed that acetaminophen provides only trivial benefits for patients with hip or knee osteoarthritis in terms of pain reduction and improvement of function and quality of life,” Machado says. The researchers also found acetaminophen to be entirely ineffective for low back pain.

hip pain
Machado and his colleagues analyzed results from 13 prior clinical trials on the effectiveness of acetaminophen and found the reductions in pain for people with hip or knee osteoarthritis were so small they wouldn’t be considered “clinically important.” Acetaminophen improved pain in these patients by an average drop of just 4 points or less on a scale of 0 to 100. On the other hand, the researchers write, previous studies show that a regular strength and flexibility exercise routines can make a big difference when it comes to pain, compared to more sedentary folks. One study found exercise resulted in an average drop of 2.3 points on a 0 to 10 pain scale, nearly 5 times the impact of acetaminophen in the current study.

Before you toss your pill bottles, it’s worth discussing the risks and benefits with your doctor, Machado says, as every patient is different. And because this review only examined low back pain and hip or knee osteoarthritis, he can’t say whether people using acetaminophen for other painful conditions are reaping any benefits.

However, should you choose another pain-relief route, you do have effective and safe options to quiet barking hip and knee joints, Machado says. “Land- and water-based exercises, strength training, weight management, and oral non-steroidal anti-inflammatory medicines (like ibuprofen) have also been shown to be effective for patients with lower limb osteoarthritis.” To help speed back pain recovery, he recommends getting some regular physical activity and avoiding bed rest. (Try these 4 exercises to ease back pain.)

One place to start is with this knee-protecting move: Using a set of light ankle weights, sit on a chair with your feet flat on the floor and your palms on the sides of the chair for balance. Slowly lift one foot until the leg is straight. Hold for a couple of seconds, then lower it back to the floor. After you’ve done 10-12, repeat on the other leg.

Eating Sesame Seeds Superior to Tylenol for Knee Arthritis.

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A remarkable study published in theInternational Journal of Rheumatic Diseasesconfirms that food is not only medicine, but sometimes superior to it.  Medical researchers working out of Tabriz University of Medical Sciences, Tabriz, Iran, sought to investigate theeffects of sesame seed supplementation on clinical signs and symptoms in patients with knee osteoarthritis.[i]

Knee osteoarthritis is a form of degenerative joint disease or degenerative arthritis localized in the knee, and causes a variety of symptoms including pain, swelling, abnormal bone growth (which can result in bone spurs), disfigured cartilage and loss of motion, and it affects as many as 12.1% of adults aged 60+, according to the CDC.[ii]  Standard therapy involves the use of NSAID drugs, many of which have been linked both to internal bleeding and significantly increased risk of cardiac mortality, which is why the researchers sought out to look for “a complementary treatment to reduce complications and costs.”

sesame_drug_comparison

The study took fifty patients with osteoarthritis of the knee, and divided them into two 25-patient groups: a sesame group, receiving 40 grams/day of powdered sesame seeds, and a standard drug therapy group, receiving two 500 mg doses of Tylenol twice a day along with 500 mg of glucosamine once daily. After two months of treatment, 22 patients in the sesame intervention group and 23 patients in the control group completed the study.

Table 1

Considering that treatment was comprised of little over an ounce and one half of sesame seeds, the results were truly remarkable. As presented in Table 1 above, there was a significant difference in pain intensity between the two groups after treatment, with the sesame group seeing the largest drop from 9.5 before treatment to 3.5 after treatment, and the control group seeing a more modest drop from 9 before treatment to 7 after treatment. Additional measurements were taken using both the Knee Injury and Osteoarthritis Outcome Score (KOOS) Questionnaire and the Timed Up and Go (TUG) Test. Both tests revealed a similar degree of positive change in both treatment and control groups, when compared to baseline. [See table 2 and table 3 below].

KOOS score sesame

Table 2 [KOOS]

TUG score

Table 3 [TUG]

Taken together, sesame was the clear winner. Not only was this food therapy superior in reducing the intensity of pain, but it was at least equal in effectiveness to Tylenol and glucosamine in both the KOOS and TUG tests. This, of course, was accomplished without the notorious side effectsassociated with Tylenol; to the contrary, sesame seed has a wide range of side benefits, which we covered recently in our article on sesame’s health benefits.

So, how much is 40 grams of sesame seed? A tablespoon of sesame seeds is approximately 9 grams. So, approximately 4 tablespoons will get you to what the study found to be a ‘clinical dose.’ Also, the researchers powdered the sesame seeds in order to enhance digestion. Remember, it is best to do this fresh with a mortar and pestle (first choice) or coffee grinder, also making sure that your seeds are raw, certified organic, and vetted to have not undergone gamma irradiation.

To truly appreciate the significance of this study, take a look at the growing body of toxicological research indicating that the unintended, adverse health effects of Tylenol (acetaminophen) far outweigh its purported benefits. We recently featured articles on the fact that even only occasional use of Tylenol may raise a child’s asthma risk 540%, and that it may be time for the FDA to remove it from the market.

For additional research on natural and/or integrative interventions for knee osteoarthritis visit our research page on the topic: knee osteoarthritis.

Article Resources

[i] Bina Eftekhar Sadat, Mahdieh Khadem Haghighian, Beitollah Alipoor, Aida Malek Mahdavi, Mohammad Asghari Jafarabadi, Abdolvahab Moghaddam. Effects of sesame seed supplementation on clinical signs and symptoms in patients with knee osteoarthritis.

[ii] CDC.gov, Osteoarthritis statistics