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At Issue: HA used as COX-2 inhibitor replacement
Orthopedics Today asked surgeons: How has your use of viscosupplementation for knee OA changed since of problems surfaced with some COX-2 inhibitors?
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Samuel J. Chmell, MD, FACS
Since the revelation of problems inherent to some COX-2 inhibitors, I have used viscosupplementation products for knee osteoarthritis (OA) approximately twice as often as I did previously. This has occurred for two reasons: I am now more reluctant to prescribe long-term oral medications because of potential side effects and/or interactions; and patients are more eager to pursue avenues of treatment, other than oral medications, for knee OA.
Samuel J. Chmell, MD, FACS, Department of Orthopedic Surgery, University of Illinois.
Douglas W. Jackson, MD
A large percentage of my use of viscosupplementation is related to the patients with OA of the knee(s) requesting to try it. They like the idea of a naturally occurring product used locally to treat their localized pathology without significant systemic effects. The increased number of patients requesting viscosupplementation is related to patient word-of-mouth and direct-to-consumer marketing. More and more of my patients prefer not to take long-term medication that affects them systemically. They are aware of the problems presented in the press and on the Internet. I have not significantly changed my use of COX-2 inhibitors because of the new information.
However, when I think a patient might benefit from their use, I try it short-term in these select patients — 1 to 2 weeks. If they feel a definite benefit related to the COX-2 inhibitor, I refer them to their primary care doctor, who can prescribe and monitor them for use longer-term.
Douglas W. Jackson, MD, medical director, ORI (a private research laboratory), Long Beach Calif., and Chief medical editor, Orthopedics Today. He indicated that his laboratory has received grants from Genzyme for studies done in a large animal model on the distribution, degradation and joint residence time of Synvisc, as well as the accuracy of needle placement in the intra-articular space of the human knee joint .
Vijay Vad, MD
I follow a step-based protocol for treating OA. Step 1 involves purified supplements with good clinical data consisting of 510 mg ginger, glucosamine 1,500 mg and 1,200 mg daily of chondroitin sulfate (Zingerflex.com) combined with arthritis-friendly exercises and modalities such as heat in the morning and ice at night. If not effective, pharmaceuticals such as Tylenol, traditional NSAIDs or COX-2 inhibitors can be used. I use COX-2 inhibitors only for those patients with a history of ulcers, those who are unable to tolerate traditional NSAIDs, or those on Coumadin. I use COX-2 inhibitors occasionally and not on a chronic basis in order to avoid potential cardiac and kidney complications, especially in diabetics. I believe that decreased use of COX-2 inhibitors in my practice has definitely increased the need for viscosupplementation, which is my third step of treatment for those who have failed steps 1 and 2. I use cortisone in step 3 only for those arthritic joints with acute pain onset with significant synovitis. Otherwise, viscosupplementation is the preferred treatment. Viscosupplementation has drawbacks in that it has limited efficacy in subgroups with obesity and grade 4 OA in our clinical trials. Viscosupplementation is ideal as an early intervention treatment in mild to moderate joint arthritis.
Vijay Vad, MD, assistant professor in rehabilitation medicine, Hospital for Special Surgery-Weill Medical College of Cornell University. He indicated that he is a consultant and preceptor for International Physicians Program for Genzyme, maker of Synvisc.
David D. Waddell, MD
Since the introduction of viscosupplementation to the United States in 1997, I have utilized them extensively in my practice, which is limited to disorders of the knee. They have proved to be a valuable tool in the treatment of knee OA. I also use selective COX-2 inhibitors and find them useful. With the FDA warnings and the withdrawal of Bextra and Vioxx from the market, I have become more selective in prescribing any systemic medications for OA knee pain. I have come to view OA of the knee as a local problem. In that light, injectable viscosupplements are local therapies that generally have only local adverse events, ie, local pain and swelling in the joint that occasionally occurs, and will usually spontaneously resolve or respond to aspiration and intra-articular steroids. Several authors have reported decreased use of analgesics and nonsteroidal medications after viscosupplementation — that has been my experience as well. In an article published in The Journal of Knee Surgery in 2006, I reported on 1,047 patients treated over a 5-year period. Pain and mobility improved and less pain medication was needed after viscosupplementation.
I predominantly use Synvisc but also used Supartz and Hyalgan. I maintain a longitudinal data base of knees injected in my practice. It records patient demographics, VAS scores, WOMAC scores, adverse events and subsequent treatments including total knee replacement. As of October, it included 4,650 knees that have received 13,846 injections.
David D. Waddell, MD, clinical associate professor of orthopedics, LSUHSC School of Medicine, and Orthopedic Specialists of Louisiana, Shreveport, LA. He indicated that he is a consultant for Genzyme Biosurgery Corp.
C. Skip Whitman, MD, FAAOS
Recent changes in labeling and warnings surrounding all anti-inflammatory medications has had an impact on my treatment algorithm for knee OA. I still feel that Celecoxib is an excellent anti-inflammatory drug and I use it regularly.
When considering treatment options for my knee OA patients, I have started to look for alternatives with more favorable risk/benefit ratios. Although I have not had any patient experience an adverse reaction to anti-inflammatory medications requiring hospitalization, I have had a good number of patients experienced associated dyspepsia and gastrointestinal intolerance from many of the commonly prescribed anti-inflammatory medications. I am more aware of the adverse events associated with NSAID’s and this has definitely affected my prescribing practice.
Having said that, I do use viscosupplementation as well in my practice and have done so regularly for the past 8 years. With all the recent publicity and medical literature regarding the risks associated with anti-inflammatory medications, I have seen an increase in my use of joint fluid therapy. I am now more likely to initiate a joint fluid therapy protocol for my patients at an earlier point in their treatment program.
I feel that viscosupplementation risks are extremely low and the potential benefits are great for the relief of pain and stiffness with an associated increase in function. Universally, my patients tolerate the joint fluid therapy protocols very well and often request repeat treatments.
In summary, my practice has changed and I have seen an increased use of viscosupplementation at an earlier stage in my treatment of the knee OA patient.
Skip Whitman, MD, Tri-Orthopedic and Sports Medicine, Elkin, N.C. He has indicated that he is a paid consultant for Smith & Nephew.