Osteoarthritis

The clinical appearance and radiological pattern of osteoarthritis have been identified in the skeletons of dinosaurs some 50-70 million years old, and in Egyptian mummies, and in ancient skeletons in England. Osteoarthritis patterns of joint involvement, often referred to as primary osteoarthritis, can be seen in the hands, spinal facet joints, hips, knees and feet, but can also be termed secondary osteoarthritis when seen in any joint that has had trauma, sepsis, surgery or metabolic insult. The prevalence of osteoarthritis increases with age. The histology and pathophysiology both demonstrate an inflammatory process. While there have been studies of genetic predisposition, the basic cause of primary osteoarthritis has not been determined.

Treatment of rheumatic musculoskeletal disorders

Non-medicinal therapies with water, salts, exercise, massage, supportive devices, and electricity have been used for centuries and continue to be of benefit for some people with musculoskeletal disorders. Historical texts refer to the two electuaries mithridatium and theriaca as early therapeutic attempts of man to provide relief of musculoskeletal symptoms and attempt disease cures. For over 200 years, morphine-derived products have been used for musculoskeletal pain. The development of acetyl salicylic acid was a major breakthrough in joint pain management. This was followed by the introduction of nonsteroidal anti-inflammatory agents, paracetamol, and the use of corticosteroids. The gold-based compounds were the initial disease-modifying drugs and have been followed by the highly successful biologics agents. The basic objectives of musculoskeletal pain management include: reduction or elimination of joint pain; improvement or restoration of joint function and mobility; improvement of muscle strength to protect cartilage, ligaments, and joint capsule; prevention and reduction of damage to joint cartilage and supporting structures.

Combined Tribological and Bactericidal Effect of Nanodiamonds as a Potential Lubricant for Artificial Joints

The artificial joints, for example, knee and hip implants, are widely used for the treatment of degenerative joint diseases and trauma. The current most common material choice for clinically used implants is the combination of polymer-on-metal structures. Unfortunately, these joints often suffer from high friction and wear, leading to associated inflammation and infection and ultimate failure of the artificial joints. Here, we propose an alternative solution to this tribologically induced failure of the joint materials. We demonstrate that the friction and wear behavior of ultrahigh-molecular-weight polyethylene (UHMWPE) and titanium tribopair, used to mimic the artificial joint interface, can be improved by introducing nanodiamond (ND) particles in the sliding contact. Characterization of the wear track using energy-dispersive spectroscopy and Raman spectroscopy revealed that the tribofilm formed from embedded NDs during sliding significantly suppressed the wear of the UHMWPE surface. In addition to the improved lubrication characteristics, NDs exhibit high biocompatibility with the bone cells and promising antibacterial properties against Staphylococcus aureus, the most common strain associated with artificial joint infection. These results indicate that NDs can be used as a promising nontoxic human-body lubricant with antiwear and antibacterial features, thus demonstrating their great potential to treat artificial joint complications through intra-articular injection.

Therapeutic Effects of Ribunucleinate (Ribonucleotides) in Immuno-Inflammatory and Arthritic Diseases

Ribonucleic acids from different organs and from yeast have been used for the treatment of chronic and degenerative diseases in the context of naturopathic medicine in the last 60 years. This chapter provides general information about ribonucleinates as therapeutic agents. Past and present pharmacological and clinical investigations are discussed in the field of the central nervous system, sensory organs, cancer and degenerative diseases of joints and vertebra.

Osteoarthritis of the hand I: aetiology and pathogenesis, risk factors, investigation and diagnosis

Objective

Osteoarthritis (OA) of the hand can be a debilitating condition that hinders an individual's quality of life. With multiple joints within the hand that are commonly affected OA, an individual's ability to use their hand in everyday movements become more limited. The article aims to review literature on the aetiology and pathogenesis of OA, risk factors, characteristics of hand OA and the steps of diagnosis.

Key findings

The aetiology and pathogenesis of OA, in particular hand OA, is not fully understood. However, it is known that several factors play a role. Environmental factors, such as stress from mechanical loading, especially to vulnerable joints predispose individuals to developing OA. Extracellular matrix changes in protein levels have also been noted in individuals with OA. Linked to hand OA development are boney enlargements (Herbeden's and Bouchard's nodes). Several risk factors for OA include: age, obesity, gender, smoking, genetics, diet and occupation. Various diagnostic methods include a combination of using radiographic methods, clinical presentation, a number of developed measurements and scales.

Summary

With OA having several risk factors and various causes and contributing elements, it is important to elucidate the pathogenesis of OA and determine exactly how risk factors play a role in its development. Because of the contributions from several elements, diagnosis is best when it uses multiple methods. In turn, understanding OA and making better diagnoses could lead to improved management of the condition through both pharmacological and non-pharmacological interventions.

Osteoarthritis of the knee and hip. Part II: therapy with ibuprofen and a review of clinical trials

OBJECTIVES

We review the pharmacological properties and clinical evidence pertaining to the efficacy of ibuprofen as a first-line treatment in hip and knee osteoarthritis (OA). In the context of our previous paper's exploration of the aetiology and pathogenesis of OA as a basis for pharmacotherapy, we discuss the pharmacokinetics (PK) and clinical pharmacodynamics (PD) of ibuprofen relevant to OA.

KEY FINDINGS

Although widely used, the benefits and risks of ibuprofen, especially compared with other non-steroidal anti-inflammatory drugs (NSAIDs) and placebo, have only recently been evaluated in OA of the hip and knee in randomized-controlled clinical trials (RCT). The efficacy and occurrence of adverse reactions from ibuprofen was compared with placebo in a structural review of the literature and systematic review of RCTs in large-scale clinical trials. Ibuprofen has been found to result in approximately 50-60% improvement over placebo in WOMAC scores, including those reflecting inflammatory joint pain in knee and hip OA or other indices of pain, disability and impaired function. Mega-trials performed in comparison with the newer NSAIDs, the coxibs, have shown that ibuprofen has comparable therapeutic benefits and although serious gastrointestinal conditions are sometimes more frequent after short-term treatment, longer-term (several months) therapy in OA reduces the advantages of the coxibs over other NSAIDs including ibuprofen. Cardiovascular risk, though present with coxibs and some NSAIDs in OA, is lower or slightly so with ibuprofen compared with coxibs.

SUMMARY

Ibuprofen is effective and relatively safe (especially at low over-the-counter doses and in the short term) for mild-to-moderate OA of the knee and hip. The PK properties of ibuprofen in OA (short plasma t½) confer advantages of this drug for OA, while evidence for clinically relevant PD benefits in joints of patients with OA, though limited, is suggestive of local anti-inflammatory activity.

Osteoarthritis of the knee and hip. Part I: aetiology and pathogenesis as a basis for pharmacotherapy

OBJECTIVES

Osteoarthritis (OA) of the knee and hip is among the most frequent and debilitating arthritic conditions. Aside from surgical intervention in severe cases, conventional treatment involves relieving painful symptoms with non-steroidal anti-inflammatory drugs (NSAIDs), narcotic and non-narcotic (weak) analgesics and physical therapy. To obtain insight into the extent of pathological changes in hip and knee OA we reviewed current literature on the pathogenesis of this state as a basis for current pharmacotherapy options.

KEY FINDINGS

Key features of the pathological joint changes in OA include: cartilage destruction by pro-inflammatory cytokines, matrix metalloproteinases and prostaglandins, which promote a catabolic environment; subchondral bone remodelling and resorption; hypertrophic differentiation of chondrocytes; neovascularisation of synovial tissue; and focal calcification of joint cartilage. Despite the central involvement of hyaline cartilage in OA pathogenesis, the source of pain likely stems from the richly innervated synovium, subchondral bone and periosteum components of the joint. Tissue damage during joint degeneration generates nociceptive stimuli. The presence of inflammatory mediators, including bradykinin, prostaglandins and leukotrienes, lowers the threshold of the Aδ and C pain fibres, resulting in a heightened response to painful stimuli.

SUMMARY

It is our opinion that it is important to base and centre the management of OA patients on the severity of patient-important outcomes, rather than purely an assessment of damage to the joint. The joint damage, as interpreted from radiographs, is not necessarily representative of the symptoms experienced. The management of OA primarily comprises pharmacological therapy, surgical interventions and various non-pharmacological interventions.

Review of the pharmaceutical properties and clinical effects of the topical NSAID formulation, diclofenac epolamine

BACKGROUND

Topical formulations of non-steroidal anti-inflammatory drugs (NSAIDs), in particular diclofenac (DI), have become popular for treating various acute and chronic painful inflammatory conditions.

OBJECTIVE

To perform a literature review of (1) the use of topical NSAIDs; (2) the pharmaceutical, pharmacokinetic and pharmacodynamic properties of a medicated plaster (patch) containing diclofenac epolamine (DI-EP, Flector Tissugel, Flector patch) compared with other formulations of topical NSAIDs; and (3) evaluation of the clinical findings from studies with this novel DI-EP patch.

OUTCOMES

(1) Pharmacokinetic studies involved determination of DI from DI-EP and separately epolamine (EP) and the epoxide metabolite (N-oxide-EP) in laboratory animals and humans; the latter being the major metabolite in humans. About 2% of DI is absorbed by the skin in humans and is excreted in the urine. Maximum plasma concentrations of 17.4 ng/mL DI are reached at 5.4 hours (approximate steady state conditions); the plasma elimination half-time (t(1/2)) being 26.4 hours. Low systemic levels of DI and EP are produced from DI-EP. Pronounced accumulation of DI occurs in the muscle layers and in synovial fluids of arthritic patients; (2) No significant toxicity occurs from EP nor N-oxide-EP, while that of oral DI-EP was similar to that from DI; and (3) In acute musculoskeletal conditions (sprains, tendonitis and sports injuries) and osteoarthritis DI-EP patches control pain and signs of joint or physical injury compared with placebo controls by 3-5 days with almost complete pain relief at 14 days. DI-EP was shown to have equivalent therapeutic effect to another DI diethylammonium gel formulation (Voltaren Emulgel). There were no reports of serious adverse events in the gastro-intestinal (GI) tract, kidneys or liver from DI-EP. Mild GI symptoms and skin reactions occur in 2 and 10% of patients, respectively.

CONCLUSIONS

The patch delivery of DI in DI-EP affords controlled delivery of the active drug in contrast to that from application of gels or ointments of NSAIDs.

Combination anti-inflammatory therapy: synergism in rats of NSAIDs/corticosteroids with some herbal/animal products

A useful function of any complementary medicine is to supplement some of the benefits from other treatment modalities. In rats, extracts from Indian celery seed and the NZ green-lipped mussel are powerful nutraceuticals that (i) amplify the potency of salicylates and prednisone for treating pre-established chronic inflammation (arthritis, fibrosis) and (ii) reduce the steroid's gastrotoxic and lymphopenic side effects. Such combinations might also be useful for treating inflammatory components of (a) osteoarthritis caused by microcrystalline hydroxyapatite (BCP) and (b) pseudo-gout, associated with calcium pyrophosphate crystals; that are usually refractory to monotherapy.

Osteoarthritis: symptoms, signs and source of pain

Osteoarthritis is the most common form of arthritis. The condition is characterised by loss or failure of the functional and/or biochemical integrity of the joint. The clinical symptoms include joint stiffness, pain and dysfunction, but the principal problem for the majority of patients is the pain. Although there are no pain receptors in the cartilage, the origin of the pain is thought to be due to stimulation of the A delta mechanoreceptors and the C polymodal nerve endings in the synovium and surrounding tissues. However, some of the pain experienced in and around the joints is referred pain or sympathetic efferent pain. In addition, there is a poor correlation of clinical symptoms with radiological or imaging appearance. This lack of correlation of clinical evaluation and imaging makes attempts at treatment difficult and compromises attempts to design studies and to evaluate the outcome of osteoarthritis in clinical trials.