The Curbsiders' 'Hot Takes'

Three Quick Tips for Managing Osteoarthritis

Matthew F. Watto, MD; Paul N. Williams, MD; Stuart K. Brigham, MD


December 13, 2019

This transcript has been edited for clarity.

Matthew F. Watto, MD: As usual, we're coming in hot. This is the Curbsiders. I am Dr Matthew Watto. Here are my two wonderful cohosts, Dr Stuart Brigham and Dr Paul Williams.

Tonight we are going to be talking about osteoarthritis (OA). We had a wonderful interview with Dr Tuhina Neogi, the chair of rheumatology at Boston University School of Medicine. But first, Paul, can you remind the audience what we do on Curbsiders? Why are we here, and what is the meaning of life?

Paul N. Williams, MD: We are the internal medicine podcast. We use expert interviews to bring you clinical pearls and practice-changing knowledge.

Watto: We had a lot of pearls from this episode, but Stuart is just champing at the bit to get his pearl out there. Stuart, what was your favorite take-home point about OA?

Stuart K. Brigham, MD: It's the fact that I feel vindicated for using topical nonsteroidal anti-inflammatory drugs (NSAIDs), specifically for knee OA. I feel great, especially when I apply them to my own knee, which is hurting right now, as we sit here.

Watto: Let's try not to spend the entire 3-5 minutes talking about your knee. Yes, you're right. Topical NSAIDs are way up front in the guidelines. They work well for knee OA, and hand OA—pretty much any joint that's not too deep. I wouldn't use them for hip OA. The 2012 American College of Rheumatology OA guidelines recommend against using them on the hip.

Brigham: And they are noninferior to oral NSAIDs, which is great, because oral NSAIDs have a plethora of adverse effects.

Watto: Exactly. Paul, what was your favorite take-home point from this episode?

Williams: I really appreciated our discussion about the role of imaging for OA. I feel like we aren't ever quite sure when to image or whether you actually have to pull the trigger to make the diagnosis or not. It turns out that if you have good enough evidence based on your history and physical examination, imaging doesn't help you all that much. If the presentation is markedly different from bread-and-butter OA, or if there's a rapid progression of symptoms or you aren't really sure what you are dealing with, then sure, go ahead and image. But if you have a patient with pain in the weight-bearing joints that are symmetric and larger, and it's behaving like OA, you don't really have to order an x-ray. It's not going to change anything. You can just go ahead and treat, rather than trying to strengthen your diagnosis.

Watto: My favorite take-home point from this was a quote from Dr Neogi: "OA is not just a disease of cartilage and bone. If we were going to rename this disease today, we'd call it total joint failure." This speaks to the fact that when you look at some of the more recent review articles about OA, they talk about all these different mechanisms—it's the synovium, it's the bone, it's the cartilage, it's every part of the knee. There's an imbalance between anabolic and catabolic forces. This has led to the potential for a lot of molecular targets moving forward. Hopefully, we are going to be looking at things that can delay progression, because at this time, the only two things that can prevent the progression of the disease are weight loss and avoiding any initial injuries or insults to the knee.

If this all sounds very interesting to you, there are a ton more pearls in the interview. We talked about a lot of things, and answered a bunch of questions from Twitter. We talked about steroid injections, turmeric, and glucosamine chondroitin.

Bad pun alert.

Brigham: That was incredibly disjointed, guys.

Click to hear the full episode of Osteoarthritis Master Class with Tuhina Neogi MD, PhD, or check out the Curbsiders on iTunes.

The Curbsiders is a national network of students, residents, and clinician educators from across the country representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about the contributors and follow them on Twitter.

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