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Concerns remain over OA-related morbidity, mortality after OARSI white paper
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LIVERPOOL, England — Two authors of the 2016 OARSI white paper outlined key data that led to the FDA’s acceptance of osteoarthritis as a serious disease and laid out future challenges for clinicians managing the disease during the OARSI World Congress on Osteoarthritis.
Gillian Hawker, MD, MSc , chair of the department of medicine and Sir John and Lady Eaton Professor of Medicine at the University of Toronto, and Nigel Arden, MD, MSc, professor in rheumatic diseases and consultant rheumatologist at the University of Southampton in the U.K., zeroed in on topics associated with epidemiology, morbidity and mortality of OA.
Hawker noted that as many as 242 million individuals worldwide have symptomatic hip or knee OA, which accounts for 3.8% of the total population.
“The total burden is unknown,” she said, stressing that OA in sites such as the back and neck are often not accounted for in data sets. “The burden may be much greater.”
The global prevalence of combined symptomatic and radiographic OA of the knee and hip may be around 2.3% for men and 4.5% for women, according to Hawker, who added that OA increases with age. “The overall prevalence is going up, and has gone up steeply since 1990,” she said.
OA carries with it a multifactorial pathogenesis, with obesity and age playing major factors, both of which are associated with physical activity. “Low physical activity has increased by 20% from 2000 to 2013,” Hawker said.
Qualitative and quantitative studies consistently show that people with OA avoid activities that exacerbate their symptoms, according to Hawker. “The problem is that exercise is by far the most important and effective treatment of hip and knee OA,” she said.
“All of this is creating a significant burden,” Hawker added. She discussed findings from the OARSI-OMERACT Initiative which indicated that pain and stiffness occurred in conjunction with poor sleep and mood disorders. “It’s not just the intensity or severity of pain, but the quality of sleep, the impact on mood and depression, the predictability of pain and the impact on function,” she said. “It’s a continuum that leads back to more pain.”
In the final component of her talk, Hawker reported on costs due to lost productivity, including intangibles such as absenteeism and presenteeism, which she defined as “reduced productivity while at work.”
In discussing comorbidities, Arden highlighted what he called the “bidirectional interaction” of treatment. For example, in patients with OA and either hypertension or cardiovascular disease, OA may limit the physical activities necessary to reduce the cardiovascular condition, while the cardiovascular condition may limit the drugs that can be used to treat OA. Similar phenomena can be observed for those with OA and diabetes mellitus, obesity, metabolic syndrome or even depression.
“This makes the comorbidities of OA a major feature of the disease,” he said. “They may impact treatment choices and are associated with poorer outcomes.”
OA-associated mortality is largely driven by cardiovascular death, according to Arden. Working from the Johnston County, North Carolina data set, he reported a 22% increase in premature mortality among patients with both symptomatic and radiographic OA. “This increase may be the disease itself, or it may be complications, including activity restriction,” he said.
Predictors of progression include baseline knee pain, varus knee alignment, Heberden’s nodes, serum hyaluronic acid and TNF-alpha. “However, none of these are strong enough to predict high risk for progression,” he said.
Arden suggested that the current treatment landscape may constitute the most important cause for concern. “There is currently no cure, and no currently licensed drugs to treat OA,” he said. Current therapies include acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, other topical NSAIDs, intra-articular corticosteroids and hyaluronic acid. “With many of these, like opioids, the risks outweigh the benefits.”
Colleagues on the surgery side tout joint replacement as a curative treatment strategy, but Arden noted that around 10% of hip replacement recipients and 20% of those with knee replacement report dissatisfaction with the procedure. “These patients are still symptomatic,” he said. “There is also the risk of perioperative mortality and infection.”
Despite these obstacles, Arden is optimistic. “OA’s acceptance by the FDA as a serious disease will allow access to accelerate the approval of drugs,” he said, and noted that the clinical community will use a similar process to encourage OA’s acceptance as a serious disease by the European Medicines Agency. – by Rob Volansky
Reference:
- Arden N. OA is a serious disease. Presented at: OARSI 2018 World Congress on Osteoarthritis; April 26-29; Liverpool, England.
- Hawker G. The burden of OA: An update on the OA epidemiology, morbidity and co-morbidity. Presented at: OARSI 2018 World Congress on Osteoarthritis; April 26-29; Liverpool, England.
Disclosure: Hawker reports no relevant financial disclosures. Healio Rheumatology could not confirm Arden’s relevant financial disclosures at the time of publication.