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Osteoarthritis (OA) is the most common form of arthritis worldwide, and ranges in the top 5-10 most disabling diseases. Contrary to common opinion, this disease is severe, often symptomatic, and may lead to loss of mobility and independence, as well as being responsible for increased frailty and excess mortality [standardized ratio: 1.55 (95% confidence interval, CI: 1.41-1.70)]. The incidence of OA increases dramatically with age in an increasingly ageing world. Therefore, practitioners involved in the management of OA often have to manage very old patients, aged 75-80 years and above, as part of their daily practice. Treatment options are limited. In addition to education and physical treatments, which are at the forefront of all treatment recommendations but require a low level of symptoms to be implemented, many pharmacological options are proposed. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as a second-line treatment but with great caution. However, the precise incidence of cardiovascular, renal, and gastrointestinal adverse events in very elderly patients is unclear. All of these risks are increased in the elderly. The relative risks can be extrapolated from various studies. However, what is the absolute risk according to age categorization? The answer to this question is important because NSAIDs should be used in very elderly patients with OA only if full information has been provided and the decision to prescribe this treatment is shared between the patient and their doctor. This article reviews the risks and currently available recommendations, and proposes practical options and warnings to allow for a responsible and limited use of NSAIDs in the very old. PLAIN LANGUAGE SUMMARY: NSAIDS in the very Old : Prescribe or Proscribe? Osteoarthritis (OA) in the very old is a serious disease leading to loss of independence, frailty, and excess mortality. Quantitative data from clinical trials and population-based observational studies on the risk of NSAID-related side effects allow the prescriber to provide more accurate information to each patient. If there is no contraindication, the decision to initiate NSAID therapy in a very old OA patient should be made in a shared manner, with the patient fully informed of the risks.
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OBJECTIVE: To determine whether cardiometabolic factors are associated with hand osteoarthritis (HOA) symptoms, radiographic severity and progression in a post hoc analysis of the phase III Strontium ranelate Efficacy in Knee OsteoarthrItis triAl (SEKOIA) trial, designed to determine the effect of strontium ranelate on knee osteoarthritis (OA). METHODS: Among the 1683 patients randomised in the SEKOIA study, 869 with radiographic HOA at baseline (rHOA≥2 joints with Kellgren-Lawrence grade ≥2) were included in a cross-sectional analysis. For longitudinal study, we included only the 307 patients with rHOA at baseline from the placebo group. We evaluated whether baseline symptomatic HOA, radiographic severity and clinical and rHOA progression were associated with coronary heart disease and/or metabolic diseases (obesity, diabetes and hypertension, dyslipidaemia) by multivariate regression analysis. RESULTS: At baseline, 869 patients (72% women) were included in the cross-sectional analysis; 26% were symptomatic. On multivariate analysis, symptomatic HOA was associated with coronary heart disease (OR 3.59, 95% CI (1.78 to 7.26)) but not metabolic diseases. After a mean follow-up of 2.6â years, for the 307 participants in the placebo group, on multivariate analysis, worse clinical HOA outcome was associated with coronary heart disease (OR 2.91, 95% CI (1.02 to 8.26)). The slow radiographic progression did not allow for revealing any associated factors. CONCLUSIONS: Symptomatic HOA and worse HOA clinical course are associated with coronary heart disease. These results strengthen the systemic component of HOA and the association between OA pain and cardiac events. TRIAL REGISTRATION NUMBER: ISRCTN41323372.
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BACKGROUND: Rheumatologic and geriatric scholarly organisations recommendations for the management of hip and knee osteoarthritis, which emphasise the usefulness of non-pharmacological therapies, are not scaled according to patient's age and physical condition. We conducted a systematic review of clinical trials on exercise and weight loss in hip and knee osteoarthritis in very old patients. METHODS: Electronic search in MEDLINE, EMBASE, PASCAL database, systematic search of the Cochrane Reviews, manual search in guidelines, meta-analyses and identified relevant articles. RESULTS: We identified 83 trials, with only 2 on patients aged ≥ 75 years; we therefore lowered the mean age threshold to 70 years and found 15 trials, mainly performed in knee osteoarthritis and outpatients. PHYSICAL EXERCISE 8 TRIALS: was effective on pain and function (4 controlled trials), with a persistent effect only in case of self-rehabilitation. AQUATIC EXERCISE 5 TRIALS: was as effective as land-based exercise. WEIGHT LOSS 2 TRIALS: only patients under diet + exercise had significant improvement on symptoms. CONCLUSION: Our systematic review confirms that international recommendations on exercise for knee osteoarthritis also apply to subjects aged 70-80 years. Long-term effectiveness requires a maintenance strategy. Specific trials on very old patients with various comorbidities are mandatory, given that these subjects are more exposed to drug-related iatrogenesis.
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OBJECTIVE: To assess the ability of avocado-soybean unsaponifiable-Expanscience (ASU-E) to slow radiographic progression in symptomatic hip osteoarthritis (OA). METHODS: Prospective, randomised, double blind, parallel group, placebo controlled 3 year trial. Patients with symptomatic (painful ≥1 year, Lequesne Index between 3 and 10) hip OA (American College of Rheumatology criteria) and a minimum joint space width (JSW) of the target hip between 1 and 4 mm on a pelvic radiograph were randomly assigned to 300 mg/day ASU-E or placebo. Standing pelvis, target hip anteroposterior (AP) and oblique views were taken annually. The primary outcome was JSW change at year 3, measured at the narrowest point on pelvic or target hip AP view (manual measure using a 0.1 mm graduated magnifying glass). The full analysis dataset (FAS) included all patients having at least two successive radiographs. An analysis of covariance Mixed Model for Repeated Measurements with Missing at Random (for missing data) was performed to compare adjusted 3 year JSW changes (primary outcome) and the percentages of 'progressors' (JSW loss≥0.5 mm) between groups. RESULTS: 399 patients were randomised (345 kept in the FAS), aged 62 (35-84) years, 54% women, mean body mass index 27 (SD 4) kg/m(2), mean symptom duration 4 (SD 5) years, 0-100 normalised Lequesne Index 30 (SD 9) and global pain visual analogue scale 37 (SD 23) mm. Mean baseline JSW was 2.8 (0.9) mm. There was no significant difference on mean JSW loss (-0.638 mm vs -0.672 mm, p=0.72, in the ASU-E and placebo groups, respectively) but there were 20% less progressors in the ASU-E than in the placebo group (40% vs 50%, respectively, p=0.040). No difference was observed on clinical outcomes. Safety was excellent. CONCLUSIONS: 3 year treatment with ASU-E reduces the percentage of JSW progressors, indicating a potential structure modifying effect in hip OA to be confirmed, and the clinical relevance requires further assessment.
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Osteoartritis de la Cadera/tratamiento farmacológico , Fitosteroles/uso terapéutico , Extractos Vegetales/uso terapéutico , Vitamina E/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Analgésicos/administración & dosificación , Antiinflamatorios no Esteroideos/administración & dosificación , Progresión de la Enfermedad , Método Doble Ciego , Esquema de Medicación , Combinación de Medicamentos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis de la Cadera/diagnóstico por imagen , Osteoartritis de la Cadera/patología , Dimensión del Dolor/métodos , Fitosteroles/efectos adversos , Fitoterapia/métodos , Extractos Vegetales/efectos adversos , Estudios Prospectivos , Radiografía , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Vitamina E/efectos adversosRESUMEN
There is no consensus regarding indications for total hip arthroplasty (THA) in hip osteoarthritis (OA). Patients can be referred to surgeons either by a general practitioner (GP) or a rheumatologist. The aim of this study was to determine whether patients referred to orthopedic surgeons by GP and rheumatologists differed. GPs and rheumatologists were asked to include one patient suffering from hip OA for whom a consultation with a surgeon was planned to determine if THA was indicated. Surgeons' decisions were obtained by follow-up questionnaires. Univariate and then multivariate statistical analysis evaluated differences between patients referred by GPs and those referred by rheumatologists. A total of 558 patients were included. THA was prescribed in 71.6 % of patients referred by rheumatologists vs. 57.6 % of patients referred by GPs (p = 0.008). Patients referred by rheumatologists were younger (66.3 vs. 69.3 years; p = 0.006), less frequently retired (72.9 vs. 84.2 %; p = 0.007), and presented with a higher New Zealand score (54.3 vs. 48.1; p = 0.0009). On multivariate analysis, the variables related to patients referred by rheumatologists were the SF-12 mental score, the New Zealand score, and the surgeon's decision. Patients consulting a surgeon to discuss THA were more likely to be operated on when referred by a rheumatologist, which might be due to differences in the rheumatologists' and GPs' opinions on the right time to perform surgery or due to differences in the populations followed by rheumatologists and GPs, those followed by rheumatologists being younger, more active, more urban, with a greater willingness to undergo surgery.
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Ortopedia/métodos , Osteoartritis de la Cadera/cirugía , Pautas de la Práctica en Medicina/estadística & datos numéricos , Reumatología/métodos , Reumatología/estadística & datos numéricos , Anciano , Artroplastia de Reemplazo de Cadera , Femenino , Médicos Generales , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Médicos , Población Rural , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To evaluate factors influencing orthopedic surgeons' decision in daily practice to recommend or not recommend total hip arthroplasty (THA) in patients with hip osteoarthritis (OA). METHODS: General practitioners and rheumatologists were asked to prospectively include 1 patient with hip OA for whom a consultation with an orthopedic surgeon was planned to determine whether or not THA was indicated. The following variables were obtained: age, sex, occupational status, body mass index, comorbidities, duration of hip OA, patient's global assessment, Western Ontario and McMaster Universities Osteoarthritis Index pain and functioning subscale scores, New Zealand score, quality of life, and structural parameters on radiographs. The surgeon's decision was obtained by followup questionnaires. Statistical analysis evaluated potential predictors of the surgeon's decision (indication for THA within the next 6 months, yes or no) using univariate and multivariate analysis. RESULTS: A total of 558 patients were included (249 men, 300 women, mean age 68.4 years, mean disease duration 4.9 years). The surgeon's decision, available for 486 patients, was to prescribe THA in 60.7% of patients. On multivariate analysis, the variables related to the surgeon's decision were the presence or absence of severe cardiovascular disease, Short Form 12 physical subscale score, and amount of joint space narrowing. CONCLUSION: While the amount of structural degradation is only slightly or not at all taken into account in numerous criteria and/or recommendations on indications for THA, it is an independent predictor of the surgeon's decision in daily practice. Such a discrepancy should be evaluated and understood in further studies.
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Artroplastia de Reemplazo de Cadera , Toma de Decisiones , Ortopedia , Osteoartritis de la Cadera/cirugía , Práctica Profesional , Anciano , Anciano de 80 o más Años , Medicina Familiar y Comunitaria , Femenino , Francia , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis de la Cadera/diagnóstico por imagen , Radiografía , Reumatología , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Osteoarthritis (OA) of the hand could be a relevant model to study the progression of OA in structure-modification trials. Various methods are proposed to assess hand OA and its progression radiologically. OBJECTIVE: To compare intra-reader and inter-reader precision and sensitivity to change of four radiological scoring methods proposed in hand OA. METHODS: 2 trained readers scored separately 105 pairs of radiographs (baseline; year 1), selected from patients enrolled in a randomised controlled trial, for inter-reader reliability and sensitivity to change. They scored twice 60 pairs among the 105 for cross-sectional and longitudinal intra-reader reliability. Radiological hand OA assessment used: global, Kellgren-Lawrence (KL), Kallman and Verbruggen scoring methods. Inter- and intra-reader reliabilities were studied using intraclass coefficient (ICC) and the Bland-Altman method. Sensitivity to change was compared by calculating the standardised response means. RESULTS: Transversal intra-reader reproducibility ICCs ranged from 0.922 to 0.999. Verbruggen ranked the highest, followed by the KL and Kallman methods. Inter-rater reliability was higher for the Verbruggen scores, followed by the KL, global and Kallman scores (ICC 0.706-0.999). Longitudinal intra-reader reliability (baseline; year 1) was better using the Kallman and KL (ICC 0.986 and 0.990), followed by the Verbruggen (0.941) or global methods (0.939). Standardised response means ranged from 0.24 (KL) to 0.29 (Kallman). CONCLUSION: All four methods compared well with respect to reliabilities. However, the Verbruggen and Kallman methods performed better. The method most sensitive to change was the Kallman method, followed by Verbruggen and global scores. This study also suggests that structural changes could be detected in hand OA over a 1-year period.
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Articulaciones de la Mano/diagnóstico por imagen , Osteoartritis/diagnóstico por imagen , Índice de Severidad de la Enfermedad , Anciano , Progresión de la Enfermedad , Métodos Epidemiológicos , Femenino , Articulaciones de la Mano/patología , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Osteoartritis/patología , RadiografíaRESUMEN
Joint space width (JSW) and narrowing (JSN) measurements on radiographs are currently the best way to assess disease severity or progression in hip osteoarthritis, yet we lack data regarding the most accurate and sensitive measurement technique. This study was conducted to determine the optimal radiograph and number of readers for measuring JSW and JSN. Fifty pairs of radiographs taken three years apart were obtained from patients included in a structure modification trial in hip osteoarthritis. Three radiographs were taken with the patient standing: pelvis, target hip anteroposterior (AP) and oblique views. Two trained readers, blinded to each other's findings, time sequence and treatment, each read the six radiographs gathered for each patient twice (time interval > or = 15 days), using a 0.1 mm graduated magnifying glass. Radiographs were randomly coded for each reading. The interobserver and intraobserver cross-sectional (M0 and M36) and longitudinal (M0-M36) reproducibilities were assessed using the intraclass coefficient (ICC) and Bland-Altman method for readers 1 and 2 and their mean. Sensitivity to change was estimated using the standardized response mean (SRM = change/standard deviation of change) for M0-M36 changes. For interobserver reliability on M0-M36 changes, the ICCs (95% confidence interval [CI]) were 0.79 (0.65-0.88) for pelvic view, 0.87 (0.78-0.93) for hip AP view and 0.86 (0.76-0.92) for oblique view. Intraobserver reliability ICCs were 0.81 (0.69-0.89) for observer 1 and 0.97 (0.95-0.98) for observer 2 for the pelvic view; 0.87 (0.78-0.92) and 0.97 (0.96-0.99) for the hip AP view; and 0.73 (0.57-0.84) and 0.93 (0.88-0.96) for the oblique view. SRMs were 0.61 (observer 1) and 0.82 (observer 2) for pelvic view; 0.64 and 0.75 for hip AP view; and 0.77 and 0.70 for oblique view. All three views yielded accurate JSW and JSN. According to the best reader, the pelvic view performed slightly better. Both readers exhibited high precision, with SRMs of 0.6 or greater for assessing JSN over three years. Selecting a single reader was the most accurate method, with 0.3 mm precision. Using this cutoff, 50% of patients were classified as 'progressors'.
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Artrografía/métodos , Articulación de la Cadera/diagnóstico por imagen , Osteoartritis de la Cadera/diagnóstico por imagen , Anciano , Progresión de la Enfermedad , Femenino , Articulación de la Cadera/patología , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Osteoartritis de la Cadera/patología , Osteoartritis de la Cadera/fisiopatología , Distribución Aleatoria , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Método Simple CiegoRESUMEN
OBJECTIVE: To evaluate the structural effect of avocado/soybean unsaponifiables (ASU) in the treatment of patients with symptomatic osteoarthritis (OA) of the hip. METHODS: Patients with regular painful primary OA of the hip (European League Against Rheumatism 1980 criteria) and a joint space still > or = 1 mm (Kellgren grade 1 to 3, assessed by an independent observer prior to inclusion) entered a prospective, multicenter, randomized, parallel group, double-blind, placebo-controlled trial of 2 years duration. Patients had at least a 6-month history of regular pain and an algofunctional index (AFI) > or = 4. The primary assessment criterion was a decrease of the joint space width (JSW) on plain anteroposterior radiographs of the pelvis performed in standing position, measured at the narrowest points by 2 independent readers, previously tested and selected and blinded to both the treatment and the time sequence. Secondary criteria were standard clinical outcome measurements (AFI, pain on a visual analog scale, consumption of nonsteroidal antiinflammatory drugs and patient's and investigator's global assessments). RESULTS: One hundred sixty-three patients were included: 102 men and 61 women (mean age 63.2 +/- 8.7 years). A total of 108 patients (72 men and 36 women; mean age 64 +/- 7.9 years) were radiologically evaluable at 23.7 +/- 2.6 months (ASU group; n = 55) and 23.7 +/- 3.2 months (placebo group; n = 53). Overall comparison of the evolution of JSW showed no difference between the ASU and placebo groups, from 2.35 +/- 0.93 to 1.87 +/- 1.10 mm and from 2.5 +/- 0.94 to 1.9 +/- 1.33 mm, respectively (intergroup P value at end point = 0.9). When patients were divided into 2 subgroups according to the median value of the baseline JSW (2.45 mm), the joint space loss in the most severely affected subgroup of patients (baseline JSW < or = median) was significantly greater in the placebo group than in the ASU group: from 1.69 +/- 0.58 to 0.84 +/- 0.77 mm (-0.86 +/- 0.62 mm) and from 1.66 +/- 0.42 to 1.22 +/- 0.7 mm (-0.43 +/- 0.51 mm), respectively (P < 0.01). The JSW decrease was identical, with no difference in ASU and placebo groups, in the less severely affected subgroup of patients (baseline JSW > median). Clinical parameters in the 2 groups did not differ significantly throughout the study. CONCLUSION: This pilot randomized, double-blind, placebo-controlled trial failed to demonstrate a structural effect of ASU in hip OA. However, in a post-hoc analysis, ASU significantly reduced the progression of joint space loss as compared with placebo in the subgroup of patients with advanced joint space narrowing. These results suggest that ASU could have a structural effect but require confirmation in a larger placebo-controlled study in hip OA.