Arthritis & Rheumatism

Guidelines for the Medical Management of Osteoarthritis

Part I. Osteoarthritis of the Hip

Marc C. Hochberg, Roy D. Altman, Kenneth D. Brandt, Bruce M. Clark, Paul A. Dieppe, Marie R. Griffin, Roland W. Moskowitz, And Thomas J. Schnitzer

Osteoarthritis (OA), formerly called degenerative joint disease, is the most prevalent form of arthritis in the United States (1). Clinically, patients with OA of the hip experience pain localized to the groin and anterior or lateral thigh, morning stiffness, and gel phenomenon, and, on physical examination, they usually have limitation and/or pain on motion of the affected hip.

Although the causes of OA of the hip are not always known, it is likely that altered biomechanical forces affecting the articular cartilage and subchondral bone, due in part to preexisting congenital and/or developmental hip disease (e.g., acetabular dysplasia, femoral head deformity) and biochemical changes in the articular cartilage, are important in its pathogenesis (2-4).

Although there is no known cure for OA of the hip, treatment designed for the individual patient can reduce pain, maintain and/or improve joint mobility, and limit functional disability. Herein, we present guidelines for the medical management of OA of the hip. These guidelines outline the use of both pharmacologic agents and nonpharmacologic modalities, including patient education and physical and occupational therapy, which are an important foundation for treatment of individuals with OA. Specific recommendations for surgical management of OA of the hip, however, are not included.

Goals of management

The goals of management of patients with OA of the hip are to control pain and other symptoms, minimize disability, and educate the patient and his or her family about the disease and its therapy. Before considering therapeutic options in an individual with OA of the hip, the physician must be certain that the patient's pain is indeed attributable to OA. For instance, it is not infrequent that a patient with a periarticular disorder such as trochanteric bursitis or piriformis syndrome is treated erroneously for hip OA.

In addition, some patients with disorders of the spine can have pain that is referred to the hip. In contrast to most patients with referred pain, patients with OA of the hip usually have pain that is localized to the groin. Therefore, it is essential that the diagnosis of OA be established before beginning therapy. The American College of Rheumatology criteria for the classification of OA of the hip have excellent precision for identifying patients with symptomatic OA of the hip (Table 1)(5). If the physician is in doubt about the diagnosis of OA, consultation with a rheumatologist should be sought.

Table 1. American College of Rheumatology classification criteria for osteoarthritis of the hip*

Traditional format Hip pain and at least 2 of the following 3 items: Erythrocyte sedimentation rate <20 mm/hour Radiographic femoral or acetabular osteophytes Radiographic joint space narrowing Classification tree Hip pain and radiographic femoral or acetabular osteophytes or Hip pain and radiographic joint space narrowing and erythrocyte sedimentation rate <20 mm/hour * Modified from ref. 5.

The treatment modalities currently available in the United States for the medical management of patients with OA of the hip are listed in Table 2. The treatment plan must be individualized, and physicians should consider any coexisting medical problems, such as hypertension, heart disease, peptic ulcer disease, or kidney disease, that would influence their decisions regarding the use of specific drug therapy.

Table 2. Medical management of patients with osteoarthritis of the hip*

Nonpharmacologic therapy Patient education Self-management programs (e.g., Arthritis Self-Help Course) Health professional social support via telephone contact Weight loss (if overweight) Physical therapy Range of motion exercises Strengthening exercises Assistive devices for ambulation Occupational therapy Joint protection and energy conservation Assistive devices for ADLs and IADLs Aerobic aquatic exercise programs Pharmacologic therapy Non-opioid analgesics (e.g., acetaminophen) Nonsteroidal antiinflammatory drugs Opioid analgesics (e.g., propoxyphene, codeine, oxycodone) * ADLs = activities of daily living; IADLs = instrumental ADLs.

Nonpharmacologic therapy

Patient education and, where appropriate, education of the patient's family, friends, or caregivers is an integral part of the treatment plan for patients with OA of the hip. Patients should be encouraged to participate in self-management programs, such as the Arthritis Self-Help Course. Individuals who attend these programs report decreased pain, decreased frequency of physician visits, and overall improvement in quality of life (6,7). Additional educational materials, including videos, pamphlets, and newsletters, are available from the Arthritis Foundation.

Another cost-effective nonpharmacologic approach for patients with OA is provision of social support via routine telephone contact. Studies of monthly telephone contact by trained nonmedical personnel to discuss such issues as joint pain, medications and treatment compliance, drug toxicities, date of next scheduled visit, and barriers to keeping clinic appointments, found moderate-to-large degrees of improvement in pain and functional status, and did not significantly increase costs (8,9). These studies underscore the concept that improved communication and education are important factors in decreasing pain and increasing function in patients with OA.

Individuals with OA of the hip may have limitations that impair their ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). These may include difficulties in walking, bathing, dressing, toileting, and performing household chores. Physical and occupational therapists play a crucial role in the management of patients with functional limitations. The physical therapist assesses muscle strength, mobility, and ambulation; may recommend the use of modalities such as heat (especially useful just prior to exercise); instructs patients in an exercise program to maintain or improve joint range of motion and periarticular muscle strength; and provides assistive devices, such as canes, crutches, or walkers to improve ambulation.

The role of exercise in the management of OA of the hip has been reviewed recently (10,11). The goals of an exercise program are to preserve at least 30[degree] of flexion and full extension of the hip, and to strengthen the hip abductors and extensors. Proper use of a cane (in the hand contralateral to the affected hip) reduces the loading forces on the joint and is associated with decreased pain and improved function (12). The cane should also be of proper height: when the subject is standing erect, with arms to the sides, the top (if a curved handle) or the level part (if a straight handle) of the handle should come to the level of the proximal wrist crease. Although no trial data are available to support this, patients may benefit from using shoe orthoses to correct abnormal biomechanics due to leg length inequality, as well as wearing shoes with viscoelastic insoles to decrease shock of impact loading (13).

The occupational therapist evaluates the patient's ability to perform ADLs and IADLs, and provides assistive devices as needed. The patient may be taught principles of joint protection and energy conservation.

For example, selected patients might be advised to live on one floor of their homes and to avoid painful step climbing, when possible.

Assistive devices, including raised toilet seats, dressing sticks for putting on socks and hose, and wall bars for getting in and out of the bathtub, can be provided. For patients with OA of the hip who have pain and/or difficulty with sexual activities, sexual counseling can be provided.

Aerobic conditioning exercises have been found to be feasible and efficacious in some patients with OA of the hip. Minor and colleagues (14) found that patients with lower extremity OA (feet, hip, and/or knee) who were randomized into an exercise program of aerobic walking or aerobic aquatics for 12 weeks showed significant improvement in aerobic capacity, 50-foot walking time, depression, anxiety, and physical activity compared with a control group who performed only range of motion exercises. To improve functional status and reduce pain, a program of aerobic activity, particularly an aquatic program such as that sponsored by the Arthritis Foundation, should be suggested to all patients with OA of the hip. These exercise programs, however, require a commitment of time and effort on the part of the patient.

Finally, epidemiologic studies have found that obesity is associated with an increased prevalence of hip OA (15); however, it is not known whether weight loss will slow the progression of existing OA or alleviate symptoms. Overweight patients with OA of the hip should be encouraged to participate in a comprehensive weight management program that includes dietary counseling and aerobic exercise. Specific dietary therapy and other unproven therapies are not recommended in the management of patients with OA of the hip (16).

Pharmacologic therapy

Pain relief is the primary indication for drug therapy in patients with OA of the hip. Currently, no drugs are available that reverse the structural or biochemical abnormalities of OA. Such ``chondroprotective'' agents or disease-modifying drugs for OA have been studied in several animal models of OA, and may be available in the future for use in humans (17).

Traditionally, nonsteroidal antiinflammatory drugs (NSAIDs) have been the agents of choice for the treatment of pain in patients with OA, including hip OA (18). Recently, however, because of concerns about possible deleterious effects of NSAIDs on articular cartilage metabolism, questions about the role of synovial inflammation in the natural progression of OA, and recognition of the greater risk of toxicity from prolonged NSAID therapy in elderly patients with OA (see below), the central role of NSAIDs in the treatment of patients with OA has been questioned (19). Although no data are available from randomized controlled clinical trials of non-opioid, simple analgesics (e.g., acetaminophen) in patients with OA of the hip, a greater proportion (23%) of community-based, practicing rheumatologists in the United States stated that they ``always'' used acetaminophen, as compared with NSAIDs (8.7%), in the management of patients with OA of the hip (Hochberg MC: unpublished data).

The nonprescription, non-opioid analgesic acetaminophen, at doses of up to 4,000 mg/day is the recommended initial drug of choice for systemic treatment of symptomatic OA of the hip. Adverse effects of therapeutic doses of acetaminophen are generally believed to be mild (18).

Acetaminophen has been linked to liver toxicity; this side effect is rare, and usually occurs in patients who consume excessive amounts of alcohol while taking the drug (20). Although long-term ingestion of acetaminophen has been associated with renal failure (21,22), this side effect has also been associated with long-term NSAID use (21,23). Thus, comparing efficacy, safety (see below), and cost, acetaminophen should be considered the preferred first-line pharmacologic therapy for patients with symptomatic OA of the hip (Figure 1).

Figure 1. Guidelines for the medical management of patients with symptomatic osteoarthritis of the hip. qid = 4 times a day; UGI = upper gastrointestinal (tract).

Opioid analgesics, such as propoxyphene, codeine, or oxycodone, should usually be avoided for long-term use, but short-term use may be helpful for the treatment of acute exacerbations of pain.

If the patient fails to respond to acetaminophen or other oral analgesics, the use of an NSAID is indicated. Many NSAIDs are available for the treatment of OA (24,25), and dosage recommendations have been published (18). In addition to aspirin, ibuprofen, and naproxen, which are currently available over-the-counter, more than a dozen prescription NSAIDs are available in the United States. They areapproximately equal in efficacy, although there is generally great variability in patients' responses. Toxicities appear to be comparable as well, although nonacetylated salicylates (e.g., choline magnesium trisalicylate, salsalate) have less renal toxicity and antiplatelet effects (25), and low-dose ibuprofen (<=1,600 mg/day) may have less serious gastrointestinal (GI) toxicity (26). Indomethacin, however, may be associated with accelerated joint destruction in patients with OA of the hip (27), and probably should not be used for long-term therapy.

Otherwise, the choice of an NSAID is empiric and determined largely by its frequency of dosage and cost (28). Because the intensity of pain in patients with OA varies from day to day as well as within a day, the use of short half-life NSAIDs on an ``as needed'' basis is preferable if they offer adequate pain relief.

Toxicity is the major reason for not recommending the use of NSAIDs as first-line therapy for patients with OA of the hip (29). Data from epidemiologic studies demonstrate that among persons ages 65 and older, 20-30% of all hospitalizations and deaths due to peptic ulcer disease were attributable to NSAID therapy (26,30). Risk factors for upper GI bleeding in patients treated with NSAIDs include age >=65, history of peptic ulcer disease or upper GI bleeding, concomitant use of oral corticosteroids and anticoagulants, and, possibly, smoking and alcohol consumption (31). Risk factors for reversible renal failure in patients with intrinsic renal disease who are treated with NSAIDs include age >=65, presence of hypertension and/or congestive heart failure, and concomitant use of diuretics and angiotensin-converting enzyme inhibitors (32). Except for the concomitant use of aspirin (at dosages of 81-325 mg/day) for its cardioprotective effect, combinations of two or more NSAIDs should not be used because of the greater risk of adverse reactions without corresponding improvement in efficacy. In addition, NSAIDs should be used with great caution in patients with aspirin sensitivity.

Several strategies have been advocated for decreasing the risk of developing upper GI complications in patients who receive NSAIDs. At present, the only drug approved by the US Food and Drug Administration (FDA) for prophylaxis is misoprostol. The cost-effectiveness of using misoprostol to treat OA patients who are receiving NSAIDs and are at an increased risk of developing these toxicities (see above) is a subject of controversy (33-35). Recommendations for the treatment of active ulcer disease and its complications in OA patients who are receiving NSAIDs are beyond the scope of these guidelines.

The efficacy of intraarticular corticosteroid injections in patients with OA of the hip has not been studied, and, because of concerns about the possible development of progressive cartilage damage through repeated injections, they are not recommended as part of routine medical management. In certain patients, however, intraarticular corticosteroid injections may be useful; this technically difficult procedure should be performed by a rheumatologist, orthopedist, or radiologist under fluoroscopic guidance.

Investigational therapy

Several experimental therapies not currently FDA-approved for use in patients with OA of the hip have been studied by rheumatologists and others in recent years, and some have shown promise as either slow-acting symptomatic drugs or disease-modifying anti-OA drugs. A discussion of these agents is beyond the scope of the present guidelines, but a review of trials of these agents in animal models of OA has been published (36). Based on the results of ongoing clinical trials, it is recognized that these guidelines may require revision if one or more of these or other agents achieves approval for marketing.

Surgical treatment

Patients with severe symptomatic OA who have pain that has failed to respond to medical therapy and progressive limitation in ADLs should be referred to orthopedic surgeons for evaluation (2,37). Osteotomy, in appropriately selected individuals, provides pain relief, and it may prevent progression of disease in patients who are not considered to be candidates for total joint arthroplasty. Total joint arthroplasty provides marked pain relief and functional improvement in the vast majority of patients with OA of the hip (38). Outcomes are dependent on the timing of the surgery, the number of procedures that the surgeon and the hospital have performed, and the patient's preoperative medical status and peri- and postoperative management and rehabilitation (39,40).

Summary

Treatment of patients with OA of the hip should be individualized and tailored to the severity of the disease. In individuals with mildly symptomatic disease, treatment may be limited to patient education, physical and occupational therapy, other nonpharmacologic modalities, and drug therapy with a non-opioid oral analgesic. In patients who are unresponsive to this treatment regimen, the use of an NSAID in addition to nonpharmacologic therapy is appropriate unless it is medically contraindicated. Patients with severe symptomatic OA of the hip require an aggressive approach to decreasing pain, increasing mobility, and improving function; such patients may benefit from orthopedic consultation and evaluation for osteotomy or total joint arthroplasty.

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Supported by a contract from the American College of Rheumatology. Approved by the Board of Directors, American College of Rheumatology, July 8, 1995.

Marc C. Hochberg, MD, MPH: the University of Maryland School of Medicine and Baltimore Veterans Affairs Medical Center, Baltimore, Maryland; Roy D. Altman, MD: the University of Miami School of Medicine and Miami Veterans Affairs Medical Center, Miami, Florida; Kennenth D. Brandt, MD: Indiana University School of Medicine, Indianapolis, Indiana; Bruce M. Clark, CPT: The Mary Pack Arthritis Centre, Vancouver, BC, Canada; Paul A. Dieppe, MD: the Bristol Royal Infirmary, University of Bristol, Bristol, UK; Marie R. Griffin, MD, MPH: Vanderbilt University School of Medicine, Nashville, Tennessee; Roland W. Moskowitz, MD: Case Western Reserve University School of Medicine, Cleveland, Ohio; Thomas J. Schnitzer, MD, PhD: Rush Medical College, Chicago, Illinois.

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