2.6 Osteoarthritis Management in GP

Question 1

When medically treating the OA patient, what are the current general recommendations?

Answer 1

75% analgesics
25% weight loss
19% exercise restriction

+/- new therapies
+/- salvage surgery

Question 2

What is in the “what works” section of OA management?

Answer 2

(1) weight loss

• best to be lean-ideal
• 12-18% weight loss significantly improves OA

(2) NSAIDs

• AA cascade
• 4-6 weeks at label dose, then taper for chronic use
• meloxicam, carprofen, firocoxib = best evidence
• if one drug does not work, wait a few days (washout) and try the next
• watch for GI upset (some liver/kidney side effects too)

(3) pripants

• prostaglandin (EP4) receptor antagonist
• e.g., grapiprant
• may affect kidneys

(4) omega-3 fatty acids

• only neutraceutical with good evidence
• n-3 > n-6 proven anti-inflamatory (affects arachidonic cascade like NSAIDs)

(5) amantadine

-It is not licensed for use for pain in dogs but contributes to pain relief by reducing the development of sensitisation to pain in the central nervous system (e.g. brain and spinal cord).
- NMDA antagonist (like ketamine): analgesic
- use if NSAID becomes insufficient

(6) corticosteroids

• “salvage” medication
• massively anti-inflammatory but can cause joint damage (+ infection risk)

(7) anti-nerve growth factor antibodies

• frunevetmab (cat monoclonal), bedinvetmab (dog monoclonal)

(8) salvage surgery: works, but no rush

• arthrodesis (fusion)
• arthroplasty (replacement or excision)
• amputation

Question 3

What is in the “what might work” category of OA management?

Answer 3

(1) botox

• inhibits pain patheay neurotranmiter release

(2) paracetamol

• NEVER cats
• treats pain not inflammation: consider if dog unresponsive to NSAIDs

(3) gabapentin

• only effective if added to exsiting drug (NSAID)

(4) disease modifying agents

• green-lipped mussel

(5) joint lubricants

• hyaluronic acid: no evidence
• polyacramide (PPAG): doesnt degrade like HA

(6) exercise

• no dog studies

(7) platelet rich plasma

• low confidence

(8) stem cell therapy

• unregulated (safe?)

(9) glucosamine and chondroitin sulfate

• not proven but no harm
• takes 2-3 months

(10) cannabidiol

• not confident but no side effects

(11) acupuncture

• no evidence in dogs

(12) laser

• no evidence for OA

Question 4

What does NOT work for OA management?

Answer 4

tramadol: has become popular but no good evidence for OA (effects likely idiosyncratic, placebo, or sedative)

also note: continued imaging “probably not useful” for evaluating progress unless significant change