Saturday, February 06, 1999
Joseph A. Buckwalter, MD, told a press conference, that "osteoarthritis is very possibly the disease of the next century." Addressing the media following the symposium on "New Approaches to Osteoarthritis," he pointed out that OA is an age-related disease and as the population ages in the decades ahead the incidence of the joint disease will sharply increase. But OA already afflicts 20 million Americans and there is a growing demand for the relief of joint pain. The public is seeking solutions until OA reaches stage when surgical remedies are needed.
Books such as "The Arthritis Cure" by Jason Theodosakis, MD, MPH and access to nutritional supplements through health food stores and Internet sources have propelled more patients to ask their doctors, "Should I use this supplement?"
Robert C. Schenck, MD, associate professor, and deputy department chairman, department of orthopaedics, University of Texas Health Science Center, San Antonio, said glucosamine and chondroitin sulfate have been widely used for a number of years in veterinary medicine. "For MDs, this is a fuzzy area," said Dr. Schenck, for while studies have established that patients experience some pain relief with mild side effects, very few have been conducted in the US. However, Dr. Schenck believes that these supplements can be a reasonable adjunct for pain relief. He tells his patients, "It's not a cure, but it's worth a try."
Dr. Schenck did offer one cautionary note regarding chondroitin sulfate, which is chemically similar to heparin. It's not known whether its use could lead to bleeding problems in patients taking anticoagulants, so patients should be cautioned.
Randy N. Rosier, MD, professor, department of orthopaedics, University of Rochester, Rochester, N.Y., discussed viscosupplement-ation, a technique used since the 1970s in veterinary medicine. It involves intra-articular injection of hyaluronic acid (derived from rooster combs) to improve the elasticity and viscosity of the synovial fluid. Two products - Hyalgan® and Synvisc® - were approved by the FDA in 1997 for use in OA of the knee. Injections are given weekly in either a three or five part series; average cost of the product is $500 for the series, which does not include the cost of giving injections.
Comparing 22 human clinical trials completed so far on hyaluronic acid, Dr. Rosier said the consensus is that injections do effect moderate improvement in symptoms. Although hyaluronic acid is cleared rapidly from the joint, the symptom relief appears to persist for six to 12 months. Adverse reactions are mild, mostly relegated to transient local reactions at the injection site. However, viscosupplementation's "exact role in our armamentarium needs to be defined," said Dr. Rosier. There is currently no information on cost vs. benefit for this therapy, nor for which patient groups (older vs. younger, early vs. late OA) would benefit the most from its use.
The growth of the Medicare population, projected to reach 80 million in another 20 years, also concerns William J. Arnold, MD, the medical director of Advanced Bio-Surfaces, Inc. in Minnetonka, Minn. He and company co-founders are currently conducting European trials of their method to restore the knee joint noninvasively. They introduce a liquid polymer arthroscopically to the surface of the tibia, which then hardens to a rubbery surface. Basically, said Dr. Arnold, insertion of the polyurethane returns the medial compartment. In patients with OA of the knee, pain is relieved. In their first series of experiments, however, the polymer detached from the bone at three months. Pain returned, and patients went on to total knee replacement. Currently working on stronger polymers and more reliable anchors to the bone, Dr. Arnold foresees the device as useful in patients who do not or cannot undergo total knee replacement. This implant could be, he said, a successful stopgap between failure of conservative management and undergoing the major surgery of total knee arthroplasty.
Richard D. Coutts, MD, adjunct professor, department of orthopaedics and rehabilitation, University of California, San Diego, gave a short summation of his presentation at the symposium, which had also included remarks on Celebrex®, the Cox-2 inhibitor which had its big splash at the American College of Rheumatology meeting last November in San Diego.
The bottom-line statement about all these treatments, said Dr. Coutts, is that "they are probably useful adjuncts in the management of OA, but not a cure."