Main stages and non-pharmacological treatment
The management of patients with osteoarthritis is divided into two key stages. The first stage aims at rapid relief of pain, reactive synovial inflammation, and muscle spasms. The second stage involves long-term efforts to preserve joint function and inhibit cartilage degradation, with the mandatory participation of a multidisciplinary team.
Non-pharmacological methods often surpass medications in significance. They include:
- Lifestyle modifications: avoiding high heels, prolonged static positioning, squatting, and heavy lifting. Body weight normalization is essential to reduce mechanical load.
- Therapeutic exercises (PT): stimulates blood circulation and cartilage nutrition. The golden rule is that exercises must be performed strictly without axial loading (lying down, sitting, in water), pain-free, and in short sessions.
- Orthopedic support: insoles, canes, walkers, and orthoses. Important: continuous wearing of braces can lead to muscle hypotrophy.
Classification of NSAIDs by selectivity of action
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the cornerstone of medical disease management. Their action is based on inhibiting the cyclooxygenase (COX) enzyme. Two isoforms of the enzyme are distinguished:
- COX-1 — a structural enzyme constitutively present in tissues. It is required for normal physiology. COX-1 inhibition causes adverse effects (primarily gastrointestinal damage).
- COX-2 — an inflammatory enzyme. It is virtually absent under normal conditions but is sharply upregulated during pathological reactions. COX-2 inhibition provides the desired therapeutic effect.
Depending on which isoform the drug targets, NSAIDs are classified into three groups:
- Nonselective inhibitors (block both forms): ibuprofen, diclofenac, indometacin (the latter has a negative effect on the cartilage itself).
- Preferentially selective COX-2 inhibitors: meloxicam, nimesulide (nimesulide can protect chondrocytes from apoptosis).
- Highly selective COX-2 inhibitors: etoricoxib, celecoxib. They are maximally stomach-safe.
Chondroprotectors and other drugs
Drugs capable of protecting the joint include chondroitin sulfate and glucosamine. They serve as "building blocks" for the extracellular matrix.
Features of chondroprotector action:
- They reduce the susceptibility of cartilage cells to destructive cytokines.
- They block enzymes that degrade cartilage tissue.
- They belong to "slow-acting" drugs: initial results appear only after 2–8 weeks of intake, but persist for up to several months after discontinuation.
Intra-articular injections of glucocorticosteroids have strict limitations. This is strictly a symptomatic, one-time measure for acute inflammation (no more than 3–4 times a year). Hormones have a destructive effect on cartilage and can precipitate osteonecrosis when injected into the hip joint.
Briefly: answers to topical questions
What are the radiographic stages of osteoarthritis according to Kellgren and Lawrence?
The Kellgren-Lawrence radiologic classification of osteoarthritis (Kellgren-Lawrence) includes the following stages:
- Stage 0 — no radiographic changes.
- Stage I (doubtful changes) — absence or near-imperceptibility of joint space narrowing, presence of minute marginal osteophytes.
- Stage II (minimal changes) — slight joint space narrowing.
Descriptions of stages III and IV are not provided in the sources, but they are mentioned as indications for surgical treatment (arthroplasty).
What is the etiological classification of osteoarthritis?
By etiology, osteoarthritis is classified into two main forms:
- Primary (idiopathic) — degenerative changes develop on initially healthy articular cartilage. It occurs when mechanical loads exceed normal levels and affect an unchanged joint. The exact cause is unclear; it develops due to the combined impact of biological and mechanical factors.
- Secondary (mechano-induced) — degeneration occurs on pre-altered cartilage under normal physiological loads. Causes include prior pathologies: trauma, intra-articular fractures, past arthritis, osteonecrosis, dysplasia, static malalignment, as well as metabolic, endocrine, neurological, and vascular disorders.
What complications can intra-articular glucocorticosteroid administration cause?
Intra-articular administration of glucocorticosteroids can cause a number of serious complications.
The main adverse effects include:
- Cartilage degeneration — the drugs have an extremely negative effect on articular cartilage, promoting the progression of its destruction.
- Osteonecrosis — this complication may occur when glucocorticosteroids are injected into the hip joint.
Due to these risks, intra-articular injections are used strictly as a one-time procedure (no more than 3–4 times a year) exclusively for managing acute inflammation and reactive synovitis.
What clinical forms of osteoarthritis exist depending on localization?
Depending on localization, the following forms of osteoarthritis are distinguished:
- Coxarthrosis — involvement of the hip joint.
- Gonarthrosis — involvement of the knee joint.
- Osteoarthritis of the hand joints — involvement of the distal and proximal interphalangeal joints, with the formation of Heberden's and Bouchard's nodes.
- TMJ osteoarthritis — involvement of the temporomandibular joint.
To remember the difference between COX isoforms, use the mnemonic: COX-1 — "First/Permanent" (protects normal physiology), COX-2 — "Secondary/Inflammatory" (appears during disease).
Class and exam questions
Can different NSAIDs be used simultaneously to enhance the effect?
No, this is strictly prohibited. Simultaneous intake of multiple NSAIDs does not enhance analgesia, but exponentially increases the risk of severe complications, especially from the gastrointestinal tract.
How to protect the stomach when taking non-selective NSAIDs?
In patients without additional risk factors, nonselective drugs must be prescribed in combination with proton pump inhibitors (e.g., omeprazole). If the risk of gastropathy is high, preferential COX-2 inhibitors are preferred.
How effective are ointments and gels in osteoarthritis?
Topical forms are effective for mild to moderate pain. Gels penetrate the skin faster than ointments. They act locally, minimize systemic adverse effects, and allow for a reduced pill dosage.
Is it permissible to massage an inflamed joint?
Massage is performed strictly outside the acute flare stage. The impact must be directed exclusively at the surrounding soft tissues (to relieve muscle spasm), rather than the joint itself.
What else to study on this topic
- Mechanisms of NSAID-induced gastropathy development and risk factors
- Traction therapy: traction modes for the knee and hip joints
- The role of educational programs in modifying patient behavioral habits
- Physiotherapeutic methods and spa-resort treatment (balneotherapy)
- Pro-inflammatory cytokine inhibitors (diacerein) in the treatment of osteoarthritis
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