Professor Li Zhanguo: Only by doing so can patients with osteoarthritis delay the progression of the disease!

Only for medical professionals to read for reference.
There are so many dry goods, and collect them soon! Under normal circumstances, when physicians receive osteoarthritis (OA) patients recommended by family doctors, they often feel that there is no good way, as if there is "no cure"-the operation starts when the patient gets heavier treatment.

However, before the operation, we were missing an important link: how to use drugs to intervene early to delay the progress of the disease? The prevalence of OA is high but the treatment is not standardized.
At present, the prevalence of OA in China is very high.

A study on the incidence of OA in various regions of China (Figure 1) found that the incidence of OA in various provinces in China was 5.
4%~13.
7%, of which the incidence was highest in the west, especially in the southwest, reaching 13.
7%.

 Figure 1 The incidence of OA in various provinces in China A multi-center cross-sectional study involving 1066 patients summarized the current status of OA treatment in China.

Among patients diagnosed with OA, the use rate of non-steroidal anti-inflammatory drugs (NSAIDs) was 56.
6%, and only 28.
9% of patients used analgesic.

Patients with joint pain often have indications for the use of disease-modifying osteoarthritis drugs (DMOADs), but currently only 37.
5% of patients use aminodextran, 2% use chondroitin sulfate, and 5.
9% use diacerex Because of this, the proportion of patients who used two or more DMOADs in combination was 15.
8%.

Only 26.
5% of patients took topical drug treatment.

The current treatment is far from being standardized.

  Figure 2 Current status of OA treatment in China OA is not only an important degenerative problem.
Inflammation intervention is very important.
As early as 2003, Professor Li Zhanguo once wrote an article on the pathogenesis of OA: local factors (obesity, trauma, muscle weakness) or systemic factors ( The cartilage or subchondral changes caused by genes, metabolism, and age will eventually lead to the increase of inflammatory factors (IL-1, IL-6, TNF-a), which play an important role in the occurrence and development of OA, rather than Simple joint degenerative disease.

 Figure 3 Professor Li Zhanguo published an article on the mechanism of OA.
The following figure is a picture of Kelly's rheumatology.
The model diagram vividly describes the role of the increase of inflammatory factors and the activation of inflammatory networks in the occurrence and development of OA.

OA is not just a problem of joint degeneration, it cannot be allowed to develop, but it must also interfere with inflammation.

 Figure 4 The model of OA.
The key points in the treatment of OA in the past ten years have not changed.
The golden triangle of OA treatment includes pain relief and delaying tissue structure damage.
Only by achieving these two points can we achieve the purpose of controlling disease activity and progress and improving the quality of life.
.

However, the current OA treatment is not standardized.
Not only is the use of drugs to delay the progression of the disease insufficient, but also the symptomatic treatment of pain is also insufficient, often allowing the disease to continue to progress.

 As early as 2003, Director Li Zhanguo’s team wrote an OA treatment guide.
The parts circled in red circle (including patient education, rehabilitation treatment, lifestyle guidance, NSAIDs and DMOADs) span ten years to this day and are still the most important ones.
Key point.

 Figure 5 Guidelines for the treatment of OA In 2015, a study reviewed the drugs for the treatment of OA in multiple international rheumatism treatment guidelines.
Generally speaking, DMOADs are always recommended for the treatment of OA.

A 2018 JAMA Mata analysis also showed that in addition to pain-relieving drugs, disease-relieving DMOADs drugs are effective in controlling the progression of OA.

 In the past ten years, the effectiveness of OA drug treatment has been controversial.

for example.

In 2006, the New England Journal of Medicine published a famous study: Are aminodextran and chondroitin sulfate useful in the treatment of OA? The general conclusion of the study is: there is no significant effect.

 Figure 6 Screenshot of the research in the "New England Journal" However, reading the article can't just look at the overall results, but also carefully interpret it.

The figure below is the most central table in this article.

The red box represents patients with severe disease, and the blue box represents patients with mild or moderate disease.

In fact, the effect is not significant for mild patients because the symptoms are not serious, but it is definitely effective for severe patients.

This led to the "invalid" result of putting together the analysis.

Therefore, aminodextran and chondroitin sulfate are still effective in the treatment of OA, and have a certain pain relief effect.

 Figure 7 Specific research content The figure below shows the research results of some large randomized controlled trials (RCT) articles after 2019.

From the perspective of the number of researches and treatments, research in the OA field, which is already a hot spot, is becoming more and more popular.

 Figure 8 RCT study and conclusions of OA treatment Here are three studies as examples: The first example is a study conducted by Zhujiang Hospital and an Australian team.
The study found that curcumin has a relieving effect on the pain of OA.

This suggests that many traditional drugs in China, whether they are on the market or not, have a lot of room for research.
Prior to this, the rigorous design of double-blind controls was a crucial step in research.

 The second example is a study published in JAMA in 2017, which showed that there is no difference between the effects of triamcinolone acetonide and normal saline injection in the joint cavity.

But the study has a problem: it is evaluated every three months, but the evaluation time is not within a few days and weeks after the injection-the time to evaluate the efficacy is too late, and the impact of this deviation should be considered.

 Figure 9 The difference between the efficacy of triamcinolone acetonide injection and normal saline for OA.
The third example is about the subtype of OA-hand osteoarthritis.

A study published in Lancet in 2019 showed that glucocorticoids are effective against osteoarthritis.

Yes, hormones are definitely effective for severe hand osteoarthritis.

But I think there is a big deviation in the study: the yellow highlighted part of the table is aggressive OA, which accounts for 74%.

In other words, hormones should be used when the diagnosis of aggressive OA is made.

To correctly understand the use of hormones in OA patients, I think the correct interpretation is: unless aggressive OA or severe OA, ordinary patients should not use hormones.

This point has been made clear in many guidelines: hormones are generally not used in OA.

 Figure 10 The effect of hormones on osteoarthritis How to distinguish aggressive OA from rheumatoid arthritis? Patients with aggressive OA have many symptoms, serious illnesses, and rapid progress.
They deserve more attention, but it is sometimes difficult to distinguish clinically.

Aggressive OA accounted for 6.
1% of OA.
Current research suggests that the incidence of aggressive OA is between 3% and 10%.

 How to distinguish aggressive OA from rheumatoid arthritis? The joint destruction of RA patients generally starts from the edge, and the joint destruction of Ero-OA generally starts from the middle, which is manifested as "seagull wing"-like changes.

 Figure 11 Comparison of Ero-OA and RA How to use DMOADs individually? The full name of DMOADs is Disease-Modifying OA Drugs.

Throughout previous classic studies, the concept of DMOADs has been widely used.

 Figure 12 Previous research on the concept of DMOADs In the past 10 years, many voices in the academic community believe that DMOADs have no clear curative effect and involve medical insurance in Western countries and are not recommended for use, resulting in no evidence for clinical application of such drugs.

In 2016, I published an article "Glucosamine is the basis and inevitable trend for the treatment of osteoarthritis" to express my position: Most patients should use DMOADs, but they should be used individually.

The triangle in the figure below is a good description of the individualized treatment method: First of all, patient education is the cornerstone of treatment: OA is not just joint degeneration, it should emphasize the correct joint exercise posture, physical exercise, weight loss, and physical therapy.

In terms of drug treatment, NSAIDs are the first choice, acetamido is not the first choice, and the use of DMOADs is an important part of the treatment.

In the late stage, strictly grasp the indications for surgery according to the situation.

In terms of joint cavity injection, local injection of hormones is effective and should be used individually and not too frequently.

Sodium hyaluronate-based intra-articular injections should be used in patients with "dry joints" and a strong sense of friction.
It is not suitable for patients with a large amount of joint effusion.

Topical medications are effective for local arthritis.
Topical medications can reduce the adverse effects of systemic medications as much as possible, but this is often neglected.
At present, the proportion of OA patients who use topical medications is less than 30%.

If you consider these aspects of the pyramid, most of the OA can get good results.

  Figure 13 The Pyramid of OA Treatment In summary, OA is the number one disease in the field of rheumatism, and clinical diagnosis and treatment are very important.

my country has a large base of OA patients, far more than rheumatoid arthritis patients.
Based on my country's current national conditions, cutting-edge research on OA should be emphasized.