Osteoarthritis: Managing without surgery
To help patients who want to “try everything” before considering joint replacement, turn to the STEPs approach.
Simplicity: Medium. Compliance (completing all 3 injections) was high in clinical trials, but is uncertain otherwise. However, injections may frequently be useless because the joint space isn’t entered. One study found that 29% of knee injections were extra-articular; placement was uncertain in another 5%. There was no correlation between successful placement and presumed expertise. This error is not surprising, considering that the articular space is usually narrowed and patients being treated for joint pain are often obese. Being able to aspirate fluid increases the chance of proper placement. (While placement errors may also occur with corticosteroid injections, that possibility is offset by a lower cost and somewhat greater likelihood of beneficial effect.)
- Consider this option only for patients with high-function goals and substantial pain or disability.
- Proceed cautiously with morbidly obese patients and patients without effusion.
- Opt for bacterial HA (Euflexxa), which has been found to be the most cost effective and have the highest efficacy and the fewest adverse effects; evidence suggests that hylan (Synvisc) should be avoided.15,16
HA injections can be repeated every 6 to 12 months if they prove to be highly beneficial. Advise patients, however, that data on repeated courses of the injections are very limited.
Nonsteroidal anti-inflammatory gel or patch
Not recommended (SOR: B).
Safety: High. Absorption is minimal, but there may be some systemic effects.
Tolerability: Medium to high, although some patients develop skin reactions to the patch and the gel.
Efficacy: Low. Pain reduction of up to 50% has been reported, but most of it is attributed to the placebo effect. The actual effect of the gel or patch averages only about 10%.21-24
Price: Medium. The gel sells for $150 to $180 per month for a quantity large enough to be used on 2 hands or 1 knee; the patch is similarly priced.
Simplicity: Low. Manufacturers recommend that the gel be applied 4 times a day, but this can prove difficult over the long term. The patch is applied only twice a day, but the painful area is usually too large or irregular for the patch to cover.
Narcotics for refractory pain
Recommended (SOR: B).
Safety: Medium. The elderly are particularly vulnerable to narcotics’ adverse effects, but the incidence of addiction and abuse in geriatric patients is very low. Recently released guidelines on the management of persistent pain from the American Geriatrics Society recommend that all older patients with moderate to severe pain or diminished quality of life be considered for narcotic therapy.25
Tolerability: Medium. Noncompliance is associated with side effects, which are usually dose-dependent. These include constipation, somnolence, and mental status changes. Reported noncompliance rates vary, in some cases reaching as high as 30%.26
Efficacy: Low to medium for weak narcotics (eg, codeine, tramadol), with about a 10% decrease in pain.26,27 However, studies generally suffer from small numbers of patients, short duration, inconsistency among clinical trials, and limited evaluation of disability and quality of life. One good study of tramadol users showed about a 15% decrease in pain among “young elders”—the total decrease in pain was 30%, including the placebo effect. Sleep quality improved and tolerability was high, with no increase in withdrawal due to adverse effects.28 For stronger narcotics (eg, morphine), direct evidence of efficacy for OA pain is lacking, but it seems reasonable to expect a medium benefit. Low-to-moderate daily doses of opioids for chronic noncancer pain—including arthritis—have been shown to improve the quality of life, compared with no narcotics or high doses.29
Price: Low (less than $20/month) for hydrocodone with acetaminophen; medium to high (more than $150/month) for long-acting morphine and transdermal fentanyl.
Simplicity: Medium to high. Twice-a-day dosing is available for long-acting strong opioids, but some narcotics must be taken 4 times a day.
