Rachmat Gunadi Wachjudi Lahir di Garut, 16-1-1955 Pendidikan SD-SMA : Garut Dokter umum: FK UNSRI Palembang Spesialis1: FK UNPAD Bandung Spesialis2: FK UI Jakarta Clinical Rheumatology & Osteoporosis training Arthritis foundation of WA Pekerjaan: Ka Div Reumatologi Dep I Peny Dalam RS Dr Hasan Sadikin Organisasi Profesi IDI, IRA, PAPDI, PEROSI, PERALMUNI
an overview of Osteoarthritis management according to OARSI, ACR and EULAR guideline
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Rachmat Gunadi Wachjudi
Lahir di Garut, 16-1-1955Pendidikan SD-SMA : Garut Dokter umum: FK UNSRI
Palembang Spesialis1: FK UNPAD Bandung Spesialis2: FK UI Jakarta Clinical Rheumatology &
Osteoporosis training Arthritis foundation of WA
Pekerjaan: Ka Div Reumatologi Dep I Peny
Dalam RS Dr Hasan SadikinOrganisasi Profesi IDI, IRA, PAPDI, PEROSI,
PERALMUNI
The Management of Osteoarthritis
Without Compromising the Patient's Safety
Rachmat Gunadi Wachjudi
Perhimpunan Reumatologi IndonesiaBandung
OA in Primary Care
■ Most patients with OA are managed in Primary Care
■ Overall, musculoskeletal problems account for 10-30 % of General Practice consultations4
■ GPs have an opportunity to optimise patient care in OA
■ Little formal evidence to support complementary therapies, but some patients derive considerable benefit
■ Examples of complementary therapies include:Acupuncture Alexander techniqueAromatherapy ChiropracticHydrotherapy MassageOsteopathy ReflexologyTai chi
■ Self-management strategies can improve patients’ ability to manage their pain and disability of OA
■ Access to patient organisations and support groups which provide help and advice PERMARIKelompok Senam Ranca Badak
Management option 7Analgesia and NSAIDs
■ Use paracetamol as first-line therapy5
■ It is likely that the majority of patients will have already tried over-the-counter paracetamol5
■ In those patients with a poor response to paracetamol, NSAIDs should be considered5
■ At ‘the lowest effective dose for the shortest possible duration’. (EMEA 27 June 2005)
Management option 7 (1)COX-2 selective inhibitors
■ Consider in patients who may be at high risk of developing serious GI adverse events, and in whom an NSAID is clearly indicated10
■ High-risk patients include, those: aged 65 years and over, with a previous clinical history of gastroduodenal ulcer, GI
bleeding or gastroduodenal perforation. The use of even a COX-2 selective agent should be considered especially carefully in this situation,
taking concomitant medication(s) that are known to increase the likelihood of upper GI adverse events (eg corticosteroids, anti-coagulants)
Management option 7 (2)COX-2 selective inhibitors
June 2005 – The European Medicines Agency reviewed Cox-2 selective inhibitors, they concluded that:
– Cox-2 selective inhibitors (Celecoxib, Etoricoxib, Lumiracoxib, Parecoxib) will have stronger guidelines for prescription:– Cox-2s should not be prescribed to people with
ischaemic heart disease, cerebrovascular disease or peripheral arterial disease
– caution when prescribing Cox-2s to people with heart disease, hypertension, hyperlipidaemia (cholesterol), diabetes and smokers
Celecoxib Efficacy in Osteoarthritis
McKenna F et al. Scand J Rheumatol 2001;30:11–18.VAS=visual analogue scale.
Less P
ain
Patient’s Assessment of Pain (VAS): Mean change at week 6
Mea
n C
ha
ng
e (m
m)
*p=0.001 vs. placebo
placebo(n=200)
celecoxib100 mg BID(n=199)
diclofenac50 mg TID(n=199)
CELECOXIB vs. diclofenac:6-week Knee OA TrialMcKenna et al. 2001: Patient’s Assessment of Pain
McKenna F et al. Scand J Rheumatol. 2001;30:11-18.
American Pain Society (APS) Pain Measure:Worst Pain in the Past 24 Hours
Mean
Ch
an
ge in
Score p=0.05, active treatment vs.
placebo (days 1-7).
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0Baseline Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
placebo (n=200)
celecoxib 100 mg BID (n=199)
diclofenac 50 mg TID (n=199)
Less P
ain
CELECOXIB vs. diclofenac:6-week Knee OA TrialMcKenna et al. 2001: American Pain Society – Pain Measure
CelecoxibGastrointestinal Safety Profile
Silverstein FE et al. JAMA. 2000;284:1247-1255.
An
nu
aliz
ed in
cid
ence
(%
)(p
er N
o. o
f p
atie
nt-
year
s)
0
1
2
3
4
Upper GI ulcercomplications
Complications andsymptomatic ulcers
P=.09
P=.02
0.76%
1.45%
2.08%
3.54%
CLASS: UGI Ulcer Complications and Symptomatic Ulcers at 6 Months—All Patients
Nonspecific NSAIDs* (n=3981)
Celecoxib 400 mg BID(n=3987)
SUCCESS=Successive Celecoxib Efficacy and Safety Study in OA.*Celecoxib 200 mg/day or 400 mg/day; †Diclofenac 50 mg BID or naproxen 500 mg BID.Singh G et al. Presented at: EULAR; June 13-16, 2001; Prague, Czech Republic.
SUCCESS-1: UGI Ulcer Complications and Symptomatic Ulcers
White et al. White et al. Am J CardiolAm J Cardiol. 2002;89:425-430. . 2002;89:425-430. Data on file. Pfizer Inc., New York, NY; FDA Advisory Committee Briefing Document. Data on file. Pfizer Inc., New York, NY; FDA Advisory Committee Briefing Document. Available at: http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4090B1_03_Pfizer-Celebrex-Bextra.pdf. Accessed January 12, 2005. Available at: http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4090B1_03_Pfizer-Celebrex-Bextra.pdf. Accessed January 12, 2005.
Medi-Cal: NSAIDs and Risk for AMI
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8
2,356,885 person-years of follow-up; 15,343 cases of AMI2,356,885 person-years of follow-up; 15,343 cases of AMI
OR for AMI (95% CI)OR for AMI (95% CI)
Singh et al. EULAR. 2005. Singh et al. EULAR. 2005.
Incidence of patients with treatment-related CV, renal, and hepatic AEs
1.71.1
4.1
5.2
0
1
2
3
4
5
6
CV / renal AE Hepatic AE
% P
atie
nts
celecoxib 200 mg OD diclofenac 50 mg BID
CELECOXIB vs. diclofenacDahlberg et al. 2009: CV / renal & hepatic AEs
One-year, randomized, multicentre, double-blind, parallel-group study to assess the AE-related discontinuation rate with celecoxib and diclofenac in elderly patients with OA.No p-values reported for related/not-related-to-treatment incidence. Significantly fewer patients in the celecoxib group than the diclofenac group experienced cardiovascular/renal AEs (70/458 vs. 95/458, p=0.039) or hepatic AEs (10/458 vs. 39/458, p<0.0001).Dahlberg LE et al. Scand J Rheumatol 2009;38:133-143.
Management option 8Symptomatic slow-acting drugs of OA
■ Symptomatic slow-acting drugs of OA (SYSADOA) glucosamine chondroitin hyaluronic acid
■ Supported by increasing evidence, although further research is still required
■ Given that these agents appear to be well tolerated and do show some benefit their use should be considered
Management option 9Corticosteroid injections
■ Corticosteroid intra-articular injections may be used in the management of patients with OA of the knee
■ Provide superior short-term efficacy (2-4 weeks) versus placebo
■ Recommended for acute exacerbations
Management option 10Surgery
■ Refer for orthopaedic evaluation if patient is disabled by OA or in pain unrelieved by medical management
■ Joint replacement can be very effective
■ Newer techniques such as metal-on-metal resurfacing are less invasive
■ Patients should be made aware of the risks and benefits of surgery
OA: Management Summary
• First: Be sure the pain is joint related (not a tendonitis or bursitis adjacent to joint)
• Initial treatment• Muscle strengthening exercises and
reconditioning walking program• Weight loss• Acetaminophen for pain relieve • Local heat/cold and topical agents• SYSADOA
OA: Management Summary (cont’d)
• Second-line approach• NSAIDs or COX-2 inhibs if acetaminophen fails• Intra-articular agents or lavage• Opioids
• Third-line • Arthroscopy• Osteotomy• Total joint replacement