Given the prevalence of osteoarthritis and the varying opinions on what constitutes effective treatment of the condition, the panelists share their insights and experience with intraarticular steroid injections as well as alternative modalities they have utilized. They also discuss the problematic aspects of osteoarthritis (OA) in the feet of patients with diabetes. Without further delay, here is what these panelists had to say.

Q: Do steroids have any role in the treatment of OA?
A: Brian Peck, MD, notes that historical teachings emphasized the use of steroids only for inflammatory arthropathies such as rheumatoid arthritis (RA). However, he says intraarticular steroid injections can be useful in cetain clinical scenarios. For example, Dr. Peck says these injections can be useful when patients have acute flares of OA in joints and certain systemic medications such as NSAIDs are contraindicated.

“Even though OA is not inflammatory as a rule, there is no question that judiciously administered intraarticular doses of steroids can usually induce improvement, sometimes considerable improvement,” explains Dr. Peck.
Karen Duclon, MSN, ARNP-BC, concurs. She says these injections can be “very helpful” in treating OA when other modalities such as acetaminophen, NSAIDs and topical therapies are not effective in relieving pain and maintaining joint function.

Patrick Astourian, MS, PA-C, has also found success with intraarticular injections when they are used in moderation.

“I believe they do have a role if they are used less then four times per year per joint,” he says. “I do have some patients that are well controlled with quarterly knee injections.”

Dr. Peck says the injection of lidocaine and steroid into the knee is “extremely effective in most cases” for treating OA of the knee.

In regard to oral steroids, Astourian says they have no role in the treatment of OA. Duclon maintains that systemic steroids have limited use in the treatment of OA “and, with few exceptions, should be avoided.”
Dr. Peck says some patients may benefit from infrequent short-term (a week or less) systemic steroid therapy. While this is not standard therapy, Dr. Peck says one may consider this in some cases in which NSAIDs are contraindicated due to heart disease, renal disease or uncontrolled hypertension, and where clinical judgment leads one to conclude that systemic steroids are the only realistic alternative.

In these clinical scenarios, Dr. Peck prefers 10 mg prednisone with a total dose of 20 tablets. He says he instructs the patient to take only four tablets (40 milligrams) for the first two mornings, then three tablets for the following two mornings and then one less every second day. Accordingly, the patient will have completed the short-term treatment regimen by the eighth day and no more steroids are administered at this point, explains Dr. Peck.

“One must be careful not to write a refillable prescription in order to avoid the possibility of inadvertent and inappropriate long-term steroid therapy,” he advises.

Q: What alternatives are there for treating OA?
A: Duclon says many patients with mild OA use acetaminophen, which is considered first-line therapy. When it comes to moderate to severe OA, Duclon says nonsteroidal antiinflammatory drugs (NSAIDs) are safe and effective for most patients in decreasing inflammation, eliminating pain and preserving joint function. However, she notes that narcotic analgesics may be required for those with gastrointestinal sensitivity to NSAIDs.

Another alternative is the combination of glucosamine and chondroitin. Both Astourian and Duclon claim that both supplements have shown to be effective in relieving OA symptoms. Astourian says there are studies for and against the use of glucosamine. He adds that some studies show that patients taking 500 mg tid of glucosamine do have similar results to those who take NSAIDs.

Astourian suggests hyaluronic acid, noting that it is a “great medication” for the knees, shoulders and ankles. In his experience, Astourian has found that after three to five treatments of Hyalgan, patients reports decreases in pain for six to 24 months.

Duclon cites the possible use of topical analgesics, including capsaicin cream and prescription analgesic patches, which can provide some pain relief and assist with mobility.

Astourian says patients with OA can use the BioniCare Knee Device stimulator by BioniCare Medical Technologies, Inc. He says patients use the device for eight hours while they are sleeping.

“There is a lot of data offered by the company that shows improvement on serial x-rays over one year,” notes Astourian.

Duclon maintains that weight loss, diet and regular exercise can significantly increase motion, decrease pain and improve the quality of life for patients with OA.

For more severe cases of OA, Astourian notes that pain management specialists may be able to perform facet blocks and epidural injections. Joint replacement is another option, according to Astourian and Duclon.
“In some cases of severe OA, surgery is necessary,” offers Duclon. “New techniques in joint replacement surgery have decreased recovery time and can improve the quality of life.”

Q: Why do people with diabetes have such bad OA of the feet?
A: Astourian says this is due to the concurrent peripheral vascular disease. As he explains, osteoarthritis is the loss of cartilage in the affected joint. Since the cartilage has such a poor blood supply, the increased atherosclerosis of the small vessels leads to the reduced ability of the chondrocytes to repair the cartilage, according to Astourian.

Duclon points out that people with diabetes can have joint changes that are similar to those with severe OA. She says this is caused by the development of neuropathic arthropathy, which is also known as Charcot’s arthopathy or Charcot’s joint.

“It is believed that joint denervation leads to physiologic changes arising from the loss of sympathetic regulation,” notes Duclon. “These changes cause an imbalance between bone resorption and formation, resulting in osteopenia.”

Duclon adds that minor trauma to foot joints and bones, along with decreased sensation, “can accelerate the arthropathy.” Dr. Peck concurs.

“The neuropathy of patients with Charcot’s arthropathy is usually severe and the presence of neuropathic pain in association with musculoskeletal pain further complicates these cases,” explains Dr. Peck.
Charoct’s arthropathy is really a form of posttraumatic OA that causes bony deformities, according to Dr. Peck. For patients with these types of deformities, Dr. Peck says wearing shoes can be a major problem and can interfere with gait. He says this condition can also cause secondary problems to the spine, hips, knees and ankles.

Here one can see traumatic osteoarthritis in the first metatarsophalangeal joint.

Duclon says a typical patient with Charcot’s arthropathy presents with swelling of the foot and ankle, erythema, warmth, pain and, frequently, skin ulcers.

“Neuropathic arthropathy can progress rapidly, occasionally rendering a joint immobile within weeks,” adds Duclon.

Mr. Astourian is a physician assistant at two rheumatology practices in El Centro and San Diego, California. He is a member of CAPA, AAPA, the Society of Physician Assistants in Rheumatolgy (SPAR) and the San Diego PA society.

Ms. Duclon is the Secretary of the West Coast Council of Advanced Nursing Practice. She is a nurse practitioner with rheumatology experience and is currently in family practice in Clearwater, FL.

Dr. Peck is an Assistant Clinical Professor of Medicine at the Yale University School of Medicine, and is an Adjunct Clinical Professor of Medicine within the Physician Assistant Program at Quinnipiac University in New Haven, Ct.