Dr Jonathan Rees is a highly experienced consultant rheumatologist and sports physician. Having trained at several London teaching hospitals, he has previously worked as a consultant at the Defence Medical Rehabilitation Centre Headley Court, acted as the Honorary Consultant Rheumatologist at Guys’ and St Thomas’ Hospitals, and been Consultant Rheumatologist at Addenbrooke’s Hospital in Cambridge. Dr Rees now works privately at Fortius Clinic London and in Cambridge, treating conditions including osteoarthritis, rheumatoid arthritis, gout, back pain and osteoporosis.
In this article, Dr Rees examines the treatment options currently available to patients with osteoarthritis and introduces Arthrosamid, an intra-articular polyacrylamide hydrogel injection (iPAAG) that works to cushion the knee joint and relieve pain in those suffering with knee osteoarthritis. He goes on to detail the types of patients he believes will benefit from Arthrosamid — explaining why this novel treatment could become a key weapon in clinicians’ fight against the disease.
Osteoarthritis (OA) is a progressive, irreversible process leading to cartilage – and joint – damage. The most common musculoskeletal condition, OA poses an enormous burden on health and social care provision in the UK, with an estimated 1 in 5 adults over the age of 45 suffering with OA of the knee and 1 in 9 adults with OA of the hip.1 It adversely affects patient’s quality of life and, potentially, their quantity of life.
OA in some patients appears to be genetically driven and can run in families; this is known as primary osteoarthritis. Secondary osteoarthritis occurs when cartilage is damaged by events such as injury or other medical conditions. These include obesity, biomechanical problems, and rheumatoid arthritis. As we live longer, the prevalence of OA rises. The knee is a highly complex joint which is frequently injured and prone to OA.
Treatment for OA can be categorised into three core groups; conservative treatment, medical treatment — which would include injections — and surgery. Unfortunately, we do not currently have any treatment that can modify the disease process itself, thus OA remains a progressive and incurable condition (unlike conditions such as rheumatoid arthritis which have numerous medications that can halt or arrest further joint damage).
Conservative treatment for OA includes weight management and patient education. Conservative intervention might see the patient wearing cushioned footwear, or orthotics and bracing. Another such intervention is to help patients become stronger and fitter through physiotherapy and conditioning exercises.
After conservative treatments, the next step in the treatment pathway is often oral medication (analgesia). Medication such as paracetamol, anti-inflammatories or codeine are commonly used. Medications including duloxetine may be offered as a second-line agent. Unfortunately, each medication has potential side effects and
the effectiveness of medications are very variable. Some medications may be used topically, such as anti-inflammatory agents or capsacian. There is some evidence that TENS machines (transcutaneous electrical nerve stimulation) can also provide some benefit in OA.
If oral or topical medication is ineffective (or inadvisable) then injection therapy may be offered. The most commonly offered injections are cortisone based. Cortisone is generally quite helpful for a flare up and often improves swelling, pain and function in the short to medium term. When cortisone works well, it can provide a period of pain-free (or pain-reduced) time where the patient can rehabilitate more effectively and become stronger. The duration of benefit can be highly variable and there are potential side effects, including lack of benefit or worsening of symptoms, cartilage degradation and the rare risk of infection.
Knee joint injection with hyaluronic acid (HA) is another option. HA is a normal component in healthy knees and injecting the knee with exogenous HA (HA made outside the body) has been shown in some studies to reduce pain and improve knee function. HA injections are usually well tolerated; however benefits can be relatively mild and HA injections are not recommended in the UK as being cost-effective for the NHS by NICE.
Other ‘niche’ techniques have been used, in particular platelet-rich plasma (PRP) as an injectable.