Rheumatologists challenged to embrace nonoperative options for OA
SAN DIEGO — Reducing use of accepted surgical and pharmacological interventions in favor of diet and exercise may be the way forward in osteoarthritis, according to a presentation at the 2019 Congress of Clinical Rheumatology West.
David Hunter, PhD, chair of the Institute of Bone and Joint Research at the University of Sydney, in Australia, said that rheumatologists often want to see patients with OA exit their clinic as quickly as possible. “They think there is not much they can do for those patients,” he said. “My job today is to change that.”
Hunter framed much of the discussion in terms of what rheumatologists can be doing less of, and what they can be doing more of. “Most of what we do today is palliate patients,” he said. “I am not sure that is the only thing we can do.”
Some of the mainstay approaches that can be used less include expensive imaging tests, referral to costly surgeries, acetaminophen, opioids, viscosupplement or corticosteroid injections, arthroscopy and even joint replacement.
For reducing imaging, Hunter urged doctors to be doctors. “You can readily diagnose most patients clinically by looking at knee pain, functional limitation, restricted range of motion,” and other factors, he said. “Imaging does not add anything to how we manage people.”
Regarding pharmacotherapeutic interventions, acetaminophen provides minimal relief for patients, while opioids clearly come with significant harms that likely do not outweigh the benefits, according to Hunter.
Similarly, he suggested that viscosupplement injections have shown no clinically meaningful benefit over saltwater injections in some studies. “This approach, along with corticosteroid injections, can be expensive and harmful,” Hunter said.
Arthroscopy is also expensive and potentially causative of pulmonary emboli with no real benefit over sham. “It is a practice that we should be actively discouraging,” Hunter said.
Regarding joint replacement, Hunter was more measured. “It is a wonderful procedure in the right patient at the right time,” he said. “But the key message is the right patient at the right time.”
As many as one in four patients are going to have a bad outcome from joint replacement, according to Hunter. “We can predict who is going to have a bad outcome,” he said. “These patients are morbidly obese, depressed, with low pain and little radiographic change. We need to triage patients better.”
Despite these reservations, trends in surgery are clearly moving in one direction. “Over the next 10 years, the projection is that joint replacement surgery is going to increase exponentially,” Hunter said. “But patients don’t necessarily want that. Most patients say they are not ready for joint replacement, and that they will try almost anything to avoid surgery.”
Shifting gears to what clinicians should be doing more of, Hunter was fairly straightforward. “We want them to exercise and lose weight,” he said. However, he acknowledged that this has been a refrain in the rheumatology community for some time, so he addressed hurdles to this goal.
“We have to give them the mechanism to do it,” he said, suggesting that many patients are uncertain of how to formulate — much less reach — fitness and weight loss goals. “Our patients have depression, they have trouble sleeping, they have pain. We need to identify what their specific problems are and tailor regimens according to those needs.”
In closing, Hunter kept the message simple. “Challenge yourself and your patients to get much more involved in nonoperative management of this disease,” he said. —by Rob Volansky
Hunter D. Update in the Therapy for Osteoarthritis. Presented at: Congress of Clinical Rheumatology West. Sept. 25-29, 2019; San Diego.
Disclosure: Hunter reports consulting for Lilly, Merck Serono, Pfizer, TLCBio, and Zynerba.