Osteoarthritis: answers to the 10 most pressing questions

Osteoarthritis of the joints is a group of diseases of a degenerative-dystrophic nature, the unifying feature of which is damage to articular tissues (bone, muscle, etc.).

The disease is classified as chronic and occurs as a result of tissue wear and tear. The development of secondary pathologies is often observed, including arthritis and arthrosis.

There are two types of osteoarthritis:

• primary is a frequently diagnosed type that affects joints of various sizes and locations. They manifest themselves predominantly as pain and stiffness, but may have various features;
• secondary – quite rare. This type of pathology is often caused by various types of injuries and pathologies.

Most often, osteoarthritis occurs as a result of inflammation or tissue damage and can be localized in various parts of the musculoskeletal system. The rate of development of the pathological condition is quite slow, which significantly complicates the diagnostic process.

In order to identify the first signs of the disease in time and be aware of the general clinical picture, it is important to know the answers to a number of important questions that are covered in this article.

How does osteoarthritis develop?

The health of the joint directly depends on the synovial fluid, which acts as an important lubricant and eliminates the possibility of friction on the surfaces of the articulation elements. In this regard, metabolic disorders play a key role in the development of joint osteoarthritis.

Biochemical disorders lead to a deterioration in the quality of synovial fluid, which significantly reduces its properties and is the starting point of destructive processes. When the lubricant deteriorates, the first thing that is negatively affected is the shell responsible for filtering the most important nutrient for connective tissue (cartilage) - hyaluronic acid, which is not only synthesized, but is also retained in the tissues with its help.

Consistently correct circulation of synovial fluid in the joint cavity ensures a full volume of substances. If this process is disrupted, there is a lack of nutrition of the cartilage, due to which its surface is deformed, which inevitably leads to the appearance of various types of defects.

Diet

A balanced diet is an important factor in the prevention and treatment of osteoarthritis. To maintain and improve joint health, you need to eat a balanced diet and consume enough protein. It is useful to eat jellied meat (cooked on the joints of birds), fish, nuts, seeds, and mature hard cheese.

To generally improve the condition of the body, reduce inflammation and improve microcirculation, it is necessary to limit the consumption of simple carbohydrates, salt, animal fats, and introduce dark-colored berries into the diet.

If you are overweight, you should stick to three meals a day, reduce the calorie content of your diet by increasing the proportion of low-starch vegetables and leafy greens, and also give up refined foods (convenience foods, canned food, confectionery).

Degrees of osteoarthritis

Today, it is customary to distinguish three key degrees of osteoarthritis, each of which is characterized by a specific clinical picture.

1st degree of osteoarthritis – initial

There is a certain soreness that occurs mainly with excessive stress on the affected joint.

As a result of the instrumental diagnostic method (radiography), a slight reduction in the joint space can be determined.

2nd degree of osteoarthritis – formation of osteophytes

At this stage, pain may appear with normal levels of physical activity, however, it can only be eliminated with the help of medications.

A characteristic feature of this stage of pathology development is a visually noticeable deformation.

Based on the results of the X-ray examination, you can notice not only a narrowing of the joint space, but also obvious bone growths.

Grade 3 osteoarthritis – severe arthrosis

The patient complains of constant pain. There is a visually noticeable, persistent deformity that leads to a noticeable violation of the axis of the limb.

Limitation of mobility leads to atrophy of the muscle frame, which can lead to a change in limb length.

Based on the results of an X-ray examination, it is impossible to determine the joint space. The surface of the articulation elements is greatly changed, and numerous bone growths are observed.

The mechanism of development of deforming arthrosis

A joint is a movable connection of bones, the surfaces of which are lined with shiny and smooth cartilage. Externally, the joint is limited by a capsule and held in place by ligaments. Inside the joint capsule is filled with synovial fluid. The complex design ensures painless and long-lasting operation of the joint even under heavy load.

Osteoarthritis begins with damage to chondrocytes, the cells of cartilage. Normally, they synthesize proteoglycans and collagen. When injured or ill, this process is disrupted. Defective chondrocytes produce defective collagen and small proteoglycans, which cannot be retained in the cartilage layer (matrix), and go into the synovial fluid.

The altered proteoglycans attract water but do not retain it. Excess moisture absorbs collagen, causing it to swell excessively and break down into fibers.

Synovial fluid loses its transparency. Articular cartilage becomes dull and rough. It gradually becomes thinner and cannot play the role of an elastic pad.

The surface of the bone, which was previously protected by cartilage, experiences increased stress and becomes denser. Bone and remnants of cartilage grow compensatory along the edges of the articular surfaces, and osteophytes - bone spines - form quite quickly.

The work of the joint becomes difficult. The situation is complicated by the activation of inflammatory and autoimmune reactions. The capsule thickens, joint mobility is sharply limited. This leads to atrophy of the corresponding muscles.

So minor primary changes lead to catastrophic consequences. Without adequate treatment, a person faces disability.

What contributes to the occurrence of osteoarthritis?

• Age

  . The disease is typical for people over 50 years of age. Over the years, the synthesis of proteoglycans and the hydrophilicity of tissues decrease. The cartilage of the joints loses its elasticity and gradually loses its ability to self-heal after microdamage. As a result, the cartilage becomes thinner, and the joint becomes sensitive even to habitual loads.

• Belonging to the female gender.

  Women get sick twice as often as men. Pathology develops with estrogen deficiency - after gynecological operations or during menopause.

• Hereditary predisposition

  . The likelihood of developing the disease is twice as high if the family has relatives suffering from osteoarthritis, and 3.5 times higher if they have Heberden’s and Bouchard’s nodes (thickening of the finger joints due to hard bone growths characteristic of deforming arthrosis).

• Joint injury or surgery

  . The integrity of individual joint structures and the nutrition of cartilage are impaired. The process of arthrosis development begins.

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• Physical overload

  . Sports and some professional activities involve heavy lifting, standing for long periods of time, or repetitive movements that put stress on the joints. The articular cartilage wears away, which gradually leads to arthrosis.

• Excess weight

  . Increases the load on supporting joints: hip and knee. Overweight women suffer from osteoarthritis four times more often than normal weight women.

• Previous illnesses

  joints, as well as chronic diseases: diabetes, gout and others, disrupt metabolic processes and impair the nutrition of cartilage. This leads to rapid wear even with normal load on the joints.

What joints are affected by osteoarthritis?

The hip and knee joints are most often affected, as they experience the greatest load. In second place is the first metatarsophalangeal joint. Third place is shared by the distal and proximal interphalangeal joints of the upper extremities (the same “bumps” appear on the fingers).

Typically, arthrosis first affects one joint, then symmetrical to it. Subsequently, the disease covers other joints. In this case, they talk about polyosteoarthrosis.

Main manifestations of osteoarthritis

• Pain
  . At first it is so insignificant that a person does not pay attention to it. The intensity of pain increases gradually and only after a few years it becomes pronounced, acquiring characteristic features.

Starting pain - intensifies at the beginning of the movement, then disappears.

Mechanical pain – when the joint is loaded, disappears after rest.

Night pain is nagging, dull, exhausting. In the morning, after starting to move, it goes away.

Referred pain can occur outside the area of ​​the affected joint.

• Morning stiffness

  . Manifested by stiffness of the diseased joint. Disappears after several movements of the limb. Never lasts more than half an hour.

• "Jaming" of the joint

  . Sudden blocking of the joint, accompanied by sharp pain. Occurs when a fragment of cartilage tissue is pinched by the articular surfaces. Disappears instantly with a certain movement of the joint.

• “Crunch” in the joint when moving

  . Caused by structural changes in cartilage tissue.

• Limited joint mobility

  . It is observed in long-term untreated osteoarthritis. Overgrown osteophytes prevent the joint from moving freely.

• Skin redness

  above the joint, swelling and increased local temperature are characteristic of reactive synovitis caused by inflammation of the synovial membrane.

• Joint deformity

  . Occurs with significant bone growths and changes in periarticular tissues in advanced cases of osteoarthritis.

Stages of the disease

1. Initial. Mild changes in the synovial membrane. Overloading the joint is accompanied by pain.
2. Second. The cartilage begins to break down. Osteophytes appear. Pain also occurs with normal activity.
3. Third. Severe arthrosis. Severe bone deformity. Sharp limitation of joint mobility. The pain bothers me even at rest.

What are the causes of osteoarthritis?

The disease in question has a fairly variable clinical picture, which depends on a large number of factors. However, despite this, a large number of diagnosed cases made it possible to identify a list of the most likely causes of osteoarthritis, which include:

• systematic loads caused by the characteristics of work or hobbies (sports, etc.);
• systematic stress, depressive states and other neurological disorders;
• genetic predisposition;
• previously suffered arthritis and arthrosis of the inflammatory type;
• the presence of infectious diseases of the musculoskeletal system;
• disruption of the endocrine system;
• complications after surgery or serious injury;
• lack of muscle tone;
• excess body weight;
• natural age-related changes;
• abuse of bad habits (smoking, drinking alcohol, overeating).

Who is at risk for joint osteoarthritis?

As with any other disease of the degenerative-dystrophic type, taking into account certain characteristics and causes of osteoarthritis, a risk group can be identified, which includes:

• people over 45 years of age, overweight and leading a sedentary lifestyle;
• women during periods of serious hormonal changes (during natural or surgically induced menopause);
• men and women of different ages who have suffered musculoskeletal injuries;
• specialists practicing heavy professional work (mainly physical), for example, loaders, drivers, sellers, etc.

What are the key symptoms of joint osteoarthritis?

Osteoarthritis is one of the special pathological conditions that have a fairly low rate of development, which indicates difficulties in diagnosis at the initial stages. For this reason, it can be seen that the symptomatic picture becomes more pronounced over time, but at the same time carries serious consequences.

Among the main symptoms of the pathological condition are:

• the appearance of painful discomfort/severe dull aching pain in the upper/lower extremities or lumbar/sacral spine;
• accompaniment of movements with a characteristic crunch;
• limitation of mobility of varying degrees, reduction in the amplitude of available movements;
• stiffness in the morning after waking up;
• barely noticeable visually, but quite noticeable inflammatory processes localized in the upper/lower extremities or various parts of the spinal column;
• aching pain that occurs mainly at night or at rest;
• inability to perform basic physical exercises;
• local swelling, swelling of tissues at the location of the disease;
• formation of osteophytes (bone growths).

It is important to note that the earlier symptoms are identified, the greater the chances of successful completion of complex and relatively quick treatment.

What is the diagnosis of joint osteoarthritis and which doctor is best to consult?

A rheumatologist diagnoses and treats diseases of the musculoskeletal system. To seek advice and receive a referral for treatment, you must first of all see a therapist who will conduct an examination, collect anamnesis and make the best decision on further actions.

Before starting treatment, each patient who seeks professional medical help with characteristic symptoms is sent for a comprehensive diagnostic examination, which involves the following stages:

• passing laboratory tests - conducting a general biochemical analysis allows you to get a fairly detailed picture of the existing disease and makes it possible to assess the level of substances contained, as well as the beginning of the development of pathological processes;
• X-ray examination - X-ray examination allows you to obtain images that clearly display the structure of the tissues and clearly visible damage to the bone or other elements of the joint, and bone formations (if any) are easily determined;
• arthroscopy is a minimally invasive diagnostic operation involving endoscopic examination of synovial fluid, the results of which provide the specialist with the opportunity to accurately assess the presence of any pathology, infection or inflammatory process.

Regardless of how intense the manifestation of the symptoms of a degenerative-dystrophic disease, in order to eliminate the possibility of making a false diagnosis, as well as to clarify the existing stage of development of pathological processes, each patient is required to undergo laboratory and x-ray examination.

How is osteoarthritis of the joints treated?

The treatment plan is determined individually, taking into account factors such as:

• collected anamnesis;
• existing complaints;
• results of diagnostic examination;
• individual characteristics of the patient.

In order to achieve the most effective result, complex treatment is used, involving procedures such as:

• drug therapy (taking drugs from groups: analgesics, glucocorticosteroids, muscle relaxants, chondroprotectors) – aimed at preventing the development of pathological and activating regenerative processes;
• physiotherapeutic methods (massage, physical therapy, exposure to electric current/magnetic field, etc.) - play the role of supportive therapy, providing the opportunity to accelerate conservative treatment and activate regenerative processes;
• surgical intervention (endoprosthetics, etc.) is important when diagnosing advanced cases. Such a radical method involves removing the source of pathological processes followed by plastic surgery of the affected fragment of the joint.

It is worth noting that drug therapy plays a vital role in the treatment of osteoarthritis, because by taking drugs it is possible not only to get rid of symptoms, but to literally eradicate the problem/its consequences.

One of the most significant groups of drugs is considered to be chondroprotectors, which help joint tissues regenerate. The most commonly prescribed drug is considered to be Artracam.

Treatment of the disease

Treatment of deforming osteoarthritis is carried out in a comprehensive manner, but at the initial stages all actions are aimed at relieving the load from the diseased joint, reducing its movements, limiting any physical activity, including carrying heavy objects.

The following treatment regimen is shown below:

• stopping the inflammatory process with non-steroidal anti-inflammatory drugs. If the patient is prone to peptic ulcers, they are prescribed topically (in the form of ointments, gels);
• intra-articular hormonal agents (for pain relief);
• for osteoarthritis that is not too advanced, chondroprotectors are used, thanks to which further destruction of damaged cartilage is stopped;
• in some cases, physiotherapeutic procedures are carried out, such as ozone therapy, paraffin therapy, electrophoresis, laser therapy, and the use of magnetic radiation;
• recreational gymnastics;
• hydrotherapy;
• kinesiotherapy;
• in advanced cases, endoprosthetics is performed.

What is the prognosis for osteoarthritis of the joints?

It is literally impossible to make unambiguous predictions in the situation under consideration.

The chances of recovery and the success of the upcoming treatment are largely determined by the timeliness of seeking professional help.

It can be noted that, considering the issue of predicting the situation from the point of eliminating morphological changes, the conclusions are not comforting, which is due to the impossibility of complete restoration of the affected tissues.

The presence of pathology in old age indicates the complexity of the course of the disease, relative to the clinical picture of younger patients.

To summarize, we can come to the conclusion that, regardless of the situation, the most positive prognosis (elimination of complaints and full/partial restoration of motor function) is possible only if you contact your doctor in a timely manner, as well as if all recommendations and prescriptions are followed.

What complications can occur in advanced cases or untreated osteoarthritis of the joints?

If the disease develops uncontrolled and there is no treatment, a person will most likely have difficulty moving independently, which significantly increases the risk of injury due to numerous bruises and falls.

Damage to the foot can lead to pain during walking and inflammation of the big toe of the lower extremity.

In the vast majority of cases, the severe form, when refusing to seek medical help, negatively affects the patient’s performance. In some cases, this can be avoided by making some changes.

Other complications include:

• loss of motor ability;
• the occurrence of chronic arthritis and arthrosis;
• loss of spinal column stability;
• complete immobilization of the limb and disability.

It is worth noting that, among other things, there are also risks of postoperative complications, for example, after arthroplasty - inflammation caused by various factors.

Disease prevention

Deforming osteoarthritis varies in speed of development depending on its location, type, age and state of the patient’s immune system.

Moderate and severe cases of neglect can lead to partial incapacity for a person, making him disabled. In some situations, it is possible to completely remove the pain and crunch, but it is no longer possible to restore the damaged cartilage and bone tissue around it.

Preventive measures for deforming osteoarthritis are as follows:

• dosing of physical activity on the joint;
• timely examination and competent treatment of various injuries to ligaments, joints and bones, such as bruises and sprains;
• proper treatment of ailments affecting the skeletal system, for example, scoliosis, flat feet, hip dysplasia;
• exercise therapy, therapeutic exercises;
• preventing obesity.

What is the prevention of osteoarthritis of the joints?

The best way to treat pathologies of any type is, of course, their prevention. We share recommendations that will reduce the risk of developing such an unpleasant and difficult to treat disease.

Maintaining a healthy lifestyle and maintaining a level of regular physical activity

There is an opinion that physical activity contributes to the wear and tear of tissues, however, in practice, things are somewhat different. Indeed, excessive loads can have a detrimental effect on the condition of the joints, but measured ones will only be beneficial.

According to studies, activity of any type, aimed primarily at strengthening the muscular frame or improving coordination, primarily supports the motor function of the joints, enriching them with useful substances due to the activation of blood circulation.

It is known that people who prefer walking are less susceptible to the risk of developing osteoarthritis.

Monitoring optimal body weight and using adequate measures to reduce it (if necessary)

Excess body weight significantly increases the load on the body, which negatively affects the functionality of the joints. Over time, due to increased load, the lower limbs and spine of an obese person may be subject to degenerative-dystrophic pathologies. For this reason, regardless of the collected anamnesis, the severity of symptoms, and other factors, physical activity (visiting exercise therapy) is necessarily included in the treatment and rehabilitation protocol.

Work on the correction and elimination of congenital deforming conditions

By deforming conditions of the congenital type, it is customary to understand a large number of diseases, among which is flat feet.

The absence of proper measures to eradicate deformities of this type can lead to a confusion of the axis of the lower extremities, as well as improper distribution of the load on individual fragments of the joints.

Compliance with the principles of balanced nutrition

“You are what you eat” is a great saying that accurately conveys the importance and significance of a nutritious, balanced diet.

Refusal of a large number of useful microelements, diet, irregular nutrition, and other factors can become a point of development of pathological processes of the degenerative-dystrophic type.

Timely seeking qualified medical care

Since the times of the USSR, it was instituted to undergo medical examination, which made it possible to timely identify pathological conditions and begin their treatment. Today, this practice is more of a advisory nature, which inevitably leads to a deterioration in the health of patients.

Refusal to consult a doctor when the first signs of illness appear sometimes leads to irreversible consequences.

Preventive use of drugs from the chondroprotector group

Proper nutrition and an active lifestyle are certainly good. However, in a situation where the body is under increased stress or for some reason cannot absorb absorbed microelements, their preventive intake comes to the rescue.

An excellently proven drug is Artracam, which belongs to the category of chondroprotectors and is one of the most effective in its segment.

There are plenty of obstacles to a full, rich life. Only the person himself can ensure the desired level of quality of life, adhering to recommendations for the prevention of various types of diseases, as well as finding positive aspects in everything and enjoying every minute he lives.

Take care of your health from a young age!

Recommendations for the management of patients with osteoarthritis of the knee joints in real clinical practice

Osteoarthritis (OA) is the most common form of arthritis and one of the leading causes of disability [1]. The most common location of OA is the knee joints, where there is a high incidence of pain [2], so this form of OA represents a good model for the development of recommendations for the treatment of the disease. Indeed, over the past 10 years, many recommendations have been proposed, including international ones, created by societies of doctors of various specialties in different countries. OA, or osteoarthritis, is currently considered not as a single disease, but rather as a syndrome that combines various phenotypic subtypes of the disease, for example, metabolic, age-related, genetic, traumatic, etc. And although the causes of such conditions are diverse, the development of the disease in all cases is due to cellular stress and degradation of the extracellular matrix that occurs with macro- or microdamage, and at the same time, non-normal adaptive repair responses are activated, including pro-inflammatory pathways of the immune system, bone remodeling and osteophyte formation.

Despite the large number of recommendations for the treatment of OA, patient management still remains a complex issue, since recommendations often contain conflicting data. A possible explanation for this lies in the variety of forms of OA, therefore, in all meta-analyses and reviews on the basis of which recommendations for the treatment of OA are created, a high heterogeneity of the population of patients included in the studies is stated, which in itself can affect the effectiveness of certain drugs for the treatment of OA ( 1).

The latest recommendations of The Osteoarthritis Research Society International (OARSI) 2014 [3] made an attempt to identify certain forms of OA, taking into account the location of the lesion and the presence of comorbidity (Fig. 2) and, based on this division, proposed a differentiated approach to treatment (Fig. 3). However, these recommendations leave a number of questions unresolved, for example, in case of a generalized process and comorbidity, intra-articular (i.a.) administration of hormones is recommended: in which joints is it not clear, since the process is generalized, but what if the patient has concomitant type 2 diabetes? Or the prescription of selective non-steroidal anti-inflammatory drugs (NSAIDs) for complications of the cardiovascular system, etc. As for medications from the group of delayed-acting symptomatic drugs, the recommendations are even more vague. Glucosamine and chondroitin sulfate are not recommended for use to slow joint space narrowing, although there are double-blind, placebo-controlled, long-term studies showing a possible structure-modifying effect. The symptomatic effect of these drugs is assessed as uncertain, although the size of the analgesic effect for chondroitin sulfate ranges from 0.13 to 0.75, for glucosamine - from 0.17 to 0.45 [4]. For other drugs in this group, recommendations are also vague.

In July 2014 [5], an algorithm for the management of patients with knee OA was proposed for practice, consistently reflecting the basic principles of OA treatment, created by a committee consisting of clinicians and scientists from different countries, the European Society for the Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, ESCEO), and taking into account not only the effectiveness, but also the safety of treatment measures.

As with all existing recommendations, the need for a combination of non-pharmacological and pharmacological treatments for OA is emphasized. Non-drug methods must necessarily include educational programs that provide the patient with knowledge about the nature of the disease and various treatment methods. These programs should contain information on lifestyle changes: reducing excess weight, ways to protect or relieve joints. In reality, it is extremely difficult to convince the patient to follow such recommendations, but it is necessary to explain that such measures, at least, will not cause increased pain or worsen the progression of the disease. It is known that a small (up to 5%) weight loss in overweight patients improves joint function to a greater extent, but does not reduce the severity of pain. Based on a recent qualitative study [6], the committee concluded that only a 10% weight loss from initial weight causes a significant reduction in OA symptoms, and furthermore, such weight loss improves the quality and thickness of the medial femoral cartilage [7]. Educational programs for patients should contain information on physical activity and physical therapy, since these methods (individual, group, home exercises) have a beneficial effect on pain and function of the knee joints [8]. Convincing data have been obtained from physical therapy in water, strength exercises for the lower extremities, quadriceps training, and aerobic exercises such as walking. And although there is no clear evidence of the effect of these methods on the progression of OA, according to experts, such programs, preferably mixed, should be mandatory for all patients [9].

However, the use of only non-drug methods after diagnosis is usually not enough, first of all, to relieve pain and improve functional status, so there is a need to add pharmacological methods for the treatment of OA.

If the patient experiences pain in the joints (Fig. 4), simultaneously with non-drug methods, medications are prescribed either in the form of monotherapy or, in case of insufficient effectiveness, a combination of drugs to more quickly achieve a satisfactory clinical effect (step 1). For the first time, the recommendations justify the participation of a physiotherapist in the treatment process, who assesses the patient’s functional status, paying special attention to deviations of the joint axis, since varus and valgus deformities are recognized risk factors not only for the development, but also for the progression of OA. The use of patellas and insoles improves the biomechanics of the joint, and, as a result, joint pain decreases, their function improves, and their long-term use even slows down the progression of the process [9]. The participation of a physiotherapist in the treatment process should not be limited to only the first stage, since in parallel with drug therapy, other treatment methods can be prescribed to further reduce pain.

One of the main goals of treatment is to reduce the symptoms of the disease. Almost all recommendations for minor joint pain recommend paracetamol in a daily dose of no more than 3.0 g due to the assumption that it is safer than other analgesics, despite the fact that it causes a slight reduction in pain. But recently, the safety of such treatment has been called into question, since data has accumulated on frequent adverse drug reactions (ADRs) from the gastrointestinal tract (GIT), increased levels of liver enzymes; in the United States, paracetamol is recognized as the most common cause of drug-induced liver damage. It would be safer to use symptomatic slow acting drugs for osteoarthritis (SYSADOA) as basic therapy, with short courses of paracetamol for rapid pain relief. The latest Cochrane review [11] showed that glucosamine (a pool of all drugs evaluated) reduces pain in OA, but there was high heterogeneity among studies, which could affect the results, especially since a subgroup analysis did not show a superiority of glucosamine over placebo in terms of pain. However, 3 studies lasting from 6 months to 3 years in OA patients with mild to moderate pain without heterogeneity, conducted in Europe, using crystallized glucosamine sulfate demonstrated its superiority over placebo in the effect on pain (effect size - 0.27 (95). % CI: 0.12–0.43) [9] and joint function (0.33 (95% CI: 0.17–0.48) [12], in other words, the effect size was the same as when using short courses of NSAIDs [13].In addition, long-term treatment with glucosamine sulfate delays the progression of OA [14].

Chondroitin sulfate also has the ability to slow down the progression of OA [15], in addition, this drug has a fairly pronounced effect on pain, and although the opinions of various researchers are not always unanimous, the size of the analgesic effect, according to some data, reaches 0.75. A recently published study showed the effectiveness of chondroitin sulfate in reducing structural changes in joints with parallel symptomatic clinically significant effects [16], which was confirmed in other work [17]. In addition to the already established effectiveness, these drugs are highly safe; the incidence of ADRs during treatment with these drugs did not differ from placebo [11, 16], which also strengthens their role as basic therapy for OA. Because of the assumption of additive effects, glucosamine and chondroitin sulfate are often used in combination. Thus, in a study conducted in America [18], it was noted that the combination of glucosamine hydrochloride and chondroitin sulfate was superior to placebo in its analgesic effect in patients with moderate and severe pain. It has now been shown that this combination had equal efficacy with celecoxib after 6 months of treatment in patients with knee OA with moderate to severe joint pain [19]. Of interest is a recently published 2-year study from Australia, which demonstrated the structure-modifying effect of this combination in knee OA [20]. The structure-modifying effect of the combination of chondroitin sulfate and glucosamine hydrochloride was also confirmed by scientists from Canada [21], when, regardless of the use of analgesics or NSAIDs, after 24 months there was less loss of cartilage volume compared to patients who did not take this combination. The effectiveness and safety of the use of combination therapy with chondroitin sulfate and glucosamine hydrochloride (Teraflex) was also confirmed by the results of a study conducted at the Scientific Research Institute of the Russian Academy of Medical Sciences in 50 outpatients with OA of the knee joints. Moreover, based on a one-year observation of 100 patients with gonarthrosis, it was demonstrated that intermittent therapy with Theraflex (treatment - 3 months, 3 months - break, 3 months of treatment) is equally effective with continuous use of the drug for 9 months in terms of its effect on pain and joint function [ 22].

As a rule, studies studying so-called delayed-release drugs (SYSADOA) are carried out with concomitant analgesic therapy: either paracetamol or NSAIDs, by reducing the dose of which the analgesic and anti-inflammatory effectiveness of the drugs under study is indirectly assessed. SYSADOA drugs usually develop their effect within 4-8-12 weeks from the start of treatment, so analgesic therapy is necessary to relieve pain.

Taking analgesics and NSAIDs when pain intensifies, together with other medications that the patient takes to treat concomitant diseases, leads, as is observed in the long-term treatment of many chronic diseases, to a decrease in adherence to treatment. It is known that compliance can be increased either by changing the treatment regimen, for example, by reducing the frequency of taking the drug, or by combining different drugs in one tablet. An open 3-month randomized comparative study of the effectiveness and safety of Teraflex Advance, containing glucosamine, chondroitin sulfate and ibuprofen, compared with Teraflex and ibuprofen in 60 patients with OA of the knee joints showed that Teraflex Advance, being well tolerated, is faster than with Teraflex, reduces pain, stiffness and improves joint function and can be recommended for OA in the first three weeks of treatment, followed by its replacement with Teraflex [23].

Evidence for other slow-acting drugs is more sparse. However, drugs from other groups appear that claim to be structure-modifying agents. For example, strontium ranelate, which acts on subchondral bone and cartilage, thereby having a positive effect on the progression of OA. A recent high-quality, 3-year, placebo-controlled study found that strontium ranelate slowed the radiographic progression of OA along with a reduction in disease symptoms [24]. The drug was well tolerated in this study, but the European Medicines Agency (EMA) recently restricted the use of this drug, recommending its use only in severe osteoporosis due to a possible increase in cardiovascular risk, hence the place of this drug in the treatment of OA in the future will need to be re-evaluated.

If after the prescribed basic treatment the patient still experiences pain, local agents can be added simultaneously with non-drug methods. The effectiveness of local remedies has been established in many studies. Randomized studies have confirmed similar effectiveness of topical and oral NSAIDs. Topical NSAIDs have better GI safety but are more likely to cause cutaneous ADRs, but studies on the effectiveness of topical agents typically average only 12 weeks and there are no long-term studies to judge long-term effects.

Committee members recommend that if the symptomatic effect is unsatisfactory, proceed to the next step 2. And here the main role traditionally belongs to NSAIDs. It is known that both selective and non-selective NSAIDs have an advantage over paracetamol in their effect on the symptoms of the disease; the effect size on pain is up to 0.29 (0.22–0.35) [13], i.e. 2 times superior to the effect of paracetamol. Indeed, patients prefer NSAIDs. Although a comparison of NSAIDs and glucosamine sulfate showed no difference in their effectiveness on pain and joint function, the committee members agreed that NSAIDs should be recommended for patients with severe pain, especially when SYSADOA does not provide the desired effect. On the other hand, when used as background therapy, SYSADOA reduces the need for NSAIDs. Recent systematic reviews have found no differences in the effectiveness of nonselective versus selective NSAIDs, so the choice of NSAID depends on the safety profile of the drug, the patient's comorbidities, and the patient's condition. COX-2 selective NSAIDs are associated with a lower incidence of ulcerogenic effects with short courses of use, but it is not clear what the situation is with long-term use, especially celecoxib and etoricoxib. Indeed, there is recent evidence that coxibs significantly increase the risk of upper gastrointestinal ADRs compared with placebo, although the risk is lower than with non-selective NSAIDs [25]. On the one hand, when prescribing non-selective NSAIDs, concomitant use of proton pump inhibitors (PPIs) is required, and on the other hand, taking into account the above and the cost-effectiveness data, the committee members believe that even in patients with a normal risk of gastrointestinal complications, doctors should consider the possibility of prescribing PPIs in combination with selective NSAIDs. In patients with a high risk of adverse reactions from the gastrointestinal tract, non-selective NSAIDs should be avoided, and selective ones should be combined with PPIs. With the combined use of Aspirin with standard NSAIDs, the risk of adverse reactions from the gastrointestinal tract also increases; in this case, selective NSAIDs partially improve tolerance from the gastrointestinal tract, and their combination with PPIs further reduces the risk of such complications.

Both standard and selective NSAIDs increase the risk of serious cardiovascular events; only Naproxen is associated with a lower risk of thrombotic cardiovascular events. A recent meta-analysis of 638 randomized trials [25] found that coxibs, diclofenac, and high-dose ibuprofen increased vascular coronary events, but not naproxen [25], so the committee recommends avoiding coxibs, diclofenac, and high-dose ibuprofen in patients with increased coronary artery disease. cardiovascular risk [25]. Data from an earlier meta-analysis [26] showed that among commonly used NSAIDs, naproxen and low-dose ibuprofen were the least likely to increase the risk of cardiovascular events. In addition, you need to remember that ibuprofen should not be prescribed together with Aspirin due to their pharmacodynamic interaction. It must be taken into account that NSAIDs can increase blood pressure, worsen the course of heart failure, and cause renal dysfunction. NSAIDs should not be prescribed to patients with chronic kidney disease with reduced creatinine clearance <30 ml/min.

If NSAIDs are contraindicated and pain persists, the use of intravenous treatment should be considered. Opinions about hyaluronic acid preparations are controversial, but there is also evidence of a positive effect of these drugs on OA of the knee joints. Data from a recent meta-analysis suggest a small effect size of 0.34 (0.22–0.46), but it is important that the positive effect persists over 6 months [27]. It should also be taken into account that intramuscular injection of hyaluronic acid preparations is generally safe, although the rare development of pseudoarthritis has been reported, especially when using high-molecular-weight drugs. In addition, hyaluronate provides long-lasting pain relief compared with steroids and may delay the need for joint replacement. A recent study showed that hyaluronic acid has similar analgesic effects to NSAIDs [28], so it may be a good alternative in elderly patients or in patients at high risk of NSAID complications.

If there is joint effusion, steroids can be used, although this recommendation is rather theoretical. Steroids are more effective than hyaluronates, but only during the first week after administration, and the duration of this effect is short, ranging from 1 to 3 weeks [29].

The last pharmacological attempts (step 3) are made in patients who are candidates for arthroplasty. The committee recommends the use of Tramadol, but the effect size is small and ADRs are common. With prolonged chronic pain, central sensitization occurs, in which case antidepressants can be used. The results of 2 randomized placebo-controlled studies showed a good effect of duloxetine within 13 weeks of use, but frequent adverse reactions were noted, including nausea, dry mouth, etc. To prescribe these drugs, it is necessary to examine the patient to identify signs of central sensitization, and in these cases it is necessary prescribe duloxetine to patients with an inadequate response to NSAIDs [30].

If the pain syndrome does not respond to therapeutic interventions, if the quality of life deteriorates significantly, surgical treatment is necessary.

Thus, the proposed algorithm for the treatment of patients with OA of the knee joints summarizes all non-drug and pharmacological methods used in the treatment of OA, and is based on existing evidence of the effectiveness of various methods. The algorithm not only substantiates a multimodal approach to the management of patients, but also offers a consistent scheme for including various methods, which represents recommendations for practicing doctors of different specialties dealing with patients with OA.

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L. I. Alekseeva, Doctor of Medical Sciences, Professor

FGBNU NIIR im. V. A. Nasonova Ministry of Health of the Russian Federation, Moscow

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