Younger Arthritics, What To Do
Case History :
Way back in 2003 a magazine reported that ARTHRITIS EPIDEMIC is growing more then ever before and the bad news is that at younger people in the society are suffering more and more . At the same time the good news is that the treatment for arthritis is more effective than ever! The arthritis of the knee can affect any age. We will have patients in the age group of 45 and 64 years who account to more than 50% of the patients in next decade. Because of the level of activities in the younger age group that demands from their knees are higher than ever. Many of the younger age group patients are willing to under go the knee replacements in order to improve the quality of life for better. The biological knee transplantation in the form of perspective articular cartilage regeneration or meniscus allograft are few increasing trends seen theses days. Best of option should be attempts to save these knees from surgical insults and provide conservative treatments focused on medication and injections which may be standard non surgical option for young arthritics. It make sense and is more effective that the attempts should be made for preservation of these knee for the long time with physical measures, weight loss and use of orthotics. In treatment of arthritis the standard "pyramidal" approach has become outdated, instead these days we customise treatment by using multimodal approach. In the pyramidal therapy, the mainstay was exercise, education, weight loss where desired. These days what we call multimodal approach , where more than one modality is chosen to be used for a particular patient simultaneously. May it be physiotherapeutic mobilisation, off loader bracing and NSAIDs for few initial days. The use of paracetamol remains as first line of medication to reduce pain of arthritis however it also remains as a leading cause of drug - induced liver failure in USA and also our part of the world. It needs monitoring and intake of more than 4gm. of acetaminophen a day has proven significantly detrimental for liver functions and can end up to liver failure. Its seen that 1-4% of NSAID users experience GI bleeding and its related complications and in elderly there is the increased risk of deaths at least 4 times more due to use of painkillers. The Cox 2 group of painkillers are also not too safe as US FDA has recommended blackbox warning to highlight potential risk of CV events and serious life-threatening GI bleeding because of their use to put on the drugs label. Hence natural contraindication of their use would be in patients suffering from hypertension and having undergone bypass surgeries, or having compromised renal functional profile. Way back in 1999 Philippi et al. reported in Military Medicine, that use of NSAIDs may accelerate disease progression through adverse effects on the cartilage metabolism or joint over use associated with an analgesia. The use of nutraceuticals in management of osteoarthritis is the big leap forward today. However their role is treatment of OA is unclear, safety and tolerance being good but the effect on the disease progression is unproven at the moment. The use of Glucosamine sulphate in combination with chondroitin has been used for long time without major evidences support on Cochrane data base. WHO has already declared this combination no better then placebo, having more adverse reactions and complications. There are newer generation of nutraceuticals like S Adenosyl methionine, curcumin, ginger, avocado extract, rose hip extract, collagen peptide type II and I, showing more promise as far as regeneration and repair of articular cartilage is concern. However their clinical efficacy may take longer time to prove and we require larger number of patients data to support that. So far we do not have any true disease modifier for curbing the menace of osteoarthritis. Is there another option that could postpone surgery in younger patients suffering from arthritis? There is very poor compliance for the patient education programs, physical therapy and occupational modifications. The importance of weight reduction, exercises and assistive devices remain still in infancy for there use in OA. The use of acetaminophen remains hepatotoxic and NSAIDs attract a very high risk of GI bleed and CV risks and renal complications. The surgical options are costly, invasive , , it may be the primary indication for "end-stage" OA, but may not be the right solutions for younger arthritics.
Investigation :
The role of Visco-supplementation or so called " regenerative" injections has been generating renewed interest for their use in arthritis of younger age group of patients in past 5 years or so. The Cochrane review of Hyaluronic acid ( Hylan -20) use in OA has proven superiority over placebo and also steroids, as far as relief in pain, improvement in activity levels and functional outcome scores are concerns. The treatment with visco-suppliment demonstrates superiority over NSAIDs, repeat injection is possible, and more that 15 million injections in US alone has been used. The use of "regenerative" injections like platelet-rich plasma has been reported to used more often in recent publications pouring in last 2 -3 years more so after 2013 -14. So in the end I have to admit that despite huge amount of research in the field of OA, there is hardly any breakthrough which could change the face of outcome for these full of life young arthritics, and hope that in near future there may be better ways or more defined armamentarium in the hand of Orthopedic surgeons and sport medicine guys.