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What does the latest research mean for people with osteoarthritis (OA)? Here is an analysis of the OA data that will be highlighted during the meeting.
A new study has found that warfarin (Coumadin), a commonly prescribed drug for atrial fibrillation, is linked to a significantly higher risk of knee replacement and hip replacement in people with osteoarthritis (OA). The research is scheduled to be presented on Saturday, November 7, 2020 at ACR Convergence, the annual meeting of the American College of Rheumatology.
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Osteoarthritis is the most common form of arthritis and affects the entire joint, including the cartilage, joint lining, ligaments, and bones. It is usually found in the hands, hips, and knees, according to the Centers for Disease Control and Prevention (CDC). When medications, physical therapy, and lifestyle changes are not effective, OA may require joint replacement.
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The researchers speculated that due to the drug’s effect on vitamin K, there may be a link between warfarin use and OA progression.
Vitamin K deficiency has been linked to OA and there is evidence that vitamin K supplementation may play a protective role in OA. This is the result of a study published in March 2016 Current nutritional reports.
Warfarin prevents blood clots from forming by blocking the activation of vitamin K-dependent proteins in the blood, according to study co-author Priyanka Ballal, MD, a rheumatology fellow at Boston University Medical Center. Based on previous research, the researchers speculated that the way warfarin works could interfere with cartilage function, which in turn could increase the risk of developing or worsening OA.
“Since direct oral anticoagulants (DOACs) are alternative options for anticoagulation that do not interfere with vitamin K function, elucidating this risk of warfarin would provide providers and patients with valuable data to evaluate their choice of anticoagulants in patients with fibrillation. atrial, “says Dr. Ballal wrote in an email.
Examples of DOAC are Pradaxa (dabigatran), Xarelto (Rivaroxaban), Eliquis (Apixaban), Savaysa (Edoxaban) and Bevyxxa (Betrixaban).
A total of 913 people with knee or hip replacement were compared with 3,652 age and sex controls. The mean age of the participants was 74 years, 54% were men, and all subjects were diagnosed with atrial fibrillation. The researchers compared people taking warfarin with those taking DOAC. Of the 913 surgical cases, 64.9% received warfarin and 35.1% received DOAC.
After checking their body mass index (BMI), existing health status, and medications, warfarin users were 1.57 more likely than DOAC patients to have a knee or hip replacement. After further considering the differences in how different health systems treat osteoarthritis, the likelihood of a warfarin user receiving replacement surgery was 1.25 times more likely, which the authors said was still a significant association. The association increased with prolonged use of the drugs.
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“These findings are important because both OA and atrial fibrillation are extremely common diseases. Unlike other types of arthritis, to date there are no disease-modifying treatments for OA, with joint replacement reserved for end-stage disease, ”Ballal wrote. With this in mind, it is very important to optimize the care for patients with OA and make sure they are not receiving therapies that worsen their OA, he added.
This research supports the importance of adequate vitamin K and dependent proteins in limiting the progression of OA, according to Ballal. “Given these potential adverse effects of warfarin on joint health, our study suggests that DOACs could be considered for the treatment of atrial fibrillation in patients with OA.”
If a patient is being treated with both warfarin and OA to treat atrial fibrillation and joint pain is exacerbated, it may warrant a discussion between the patient’s rheumatologist and the cardiologist or GP to consider switching therapy to a patient. DOAC, Ballal said.
“If you need a blood thinner, your doctor should probably know if you have significant osteoarthritis of the hip or knee,” agrees Dr. Stanford Shoor, a researcher and rheumatologist at Stanford Health Care in Palo Alto, California, was not involved in the study.
“Keep in mind that this research does not say that if you take warfarin, the chance of replacing the knee or hip is 1.5 higher than if you were given a direct oral anticoagulant,” says Dr. Shoor. This increased risk affected the small segment of people whose OA was so advanced that the joint needed to be replaced, he adds.
“If you are concerned about the potentially increased risk, talk to your doctor. If your GP is unaware of the research on this topic, you may need to see a specialist and give them a recommendation on which drug is right for you, ”Shoor says.
This evidence isn’t enough to require that anyone with OA and on warfarin therapy should rush to their doctor to change their medications, Shoor says. “This evidence shows the possibility of a relationship exists,” he says.
The next steps in research on vitamin K and its role in OA progression are in the planning stages and include designing and starting a randomized trial powerful enough to test the efficacy of vitamin K supplementation for the ‘OA, wrote Ballal.
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The new research results will be presented on Monday 9 November.In 2020, the ACR Convergence found that three months of treatment with oral methotrexate, a drug used to treat inflammatory types of arthritis such as rheumatoid arthritis, led to significant improvements in physical function and inflammation in people with primary osteoarthritis. of the knee (KOA).
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Many people with knee osteoarthritis experience signs of joint inflammation such as swelling, warmth, and pain. According to Biswadip Ghosh, MD, Associate Professor in the Department of Rheumatology at the Institute for Postgraduate Medical Education and Research in Kolkata, India, the various therapies that can help improve inflammation have several advantages and disadvantages.
For most patients, anti-inflammatory pain relievers (NSAIDs) such as aspirin, diclofenac, or celecoxib work better than acetaminophen, which has no anti-inflammatory effects, wrote Dr. Ghosh in an e-mail message. “However, NSAIDs have side effects when used continuously,” he added.
According to the U.S. Food and Drug Administration (FDA), all NSAIDs have a higher risk of gastrointestinal bleeding for people who take them daily.
Steroids can be injected into the knee to reduce the inflammation and pain associated with osteoarthritis of the knee. However, some people are afraid of needles, and repeated injections can lead to other problems, according to Ghosh.
To see if oral methotrexate could be an effective way to treat OA, the researchers compared it to a placebo treatment, glucosamine, a common supplement for relieving pain in arthritis. People could be included in the study if they had swelling and pain in both knee joints for at least six months and also had evidence of OA on their X-rays.
People were excluded if they had had arthroscopy, a steroid injection in the knee or diabetes, gout, or uncontrolled liver or kidney disease in the past three months.
A total of 249 subjects with signs of local inflammation and an increase in inflammation markers in their blood samples were included in the study’s inflammation group and then randomly selected to receive 15 to 20 milligrams (mg) of oral methotrexate. per week or 1500 mg of methotrexate per week and glucosamine were checked once per month for three months. These subjects were allowed to take acetaminophen or tramadol for pain if needed and were given NSAIDs for 7-10 days at the start of the study to improve compliance.
The study results showed that after three months, patients with primary knee OA with signs of inflammation had significant improvements in the Western Ontario and McMaster Universities Arthritis (WOMAC) index, which measures pain, stiffness and physical function. as well as a reduction in the inflammatory markers used in the study were erythrocyte sedimentation rate and C reactive protein. People taking glucosamine showed no significant improvement in these measures of function and inflammation.
The researchers concluded that methotrexate could be an effective intervention for people with knee OA suffering from pain and inflammation. “Methotrexate is taken once a week, which is very convenient and inexpensive,” Ghosh added.
“This study examines methotrexate, a treatment that is well accepted in rheumatoid arthritis, where autoimmune inflammation drives disease and causes joint damage, and examines its effectiveness in a disease that causes inflammation in a small group of people there. ‘inflammation is secondary to the gradual inability of cartilage cells to reproduce, ”explains Shoor.
“These results are very preliminary, but the study is very interesting,” says Shoor. “I don’t know how strong the effect of the abstract data I see was,” he adds.
Although the subjects in this study saw improvements, this drug would likely only be suitable for a very limited number of people, Shoor says. “I’m not convinced that many patients with this type of knee OA will want to take methotrexate for their osteoarthritis, largely due to the very significant side effects,” he says.
Although most side effects are short-term and reversible, methotrexate can cause significant nausea and fatigue, Shoor says. “Increases in liver enzymes or insufficient reduction in blood cell counts are also common, and about 10 percent of patients also experience hair loss,” he adds.
“This drug can be an excellent drug when used with caution and supervision in rheumatoid arthritis, but when used in OA, it is experimental,” says Shoor. “I would be interested to see the results of this study in more detail and see further research in the future that resembles methotrexate in a small group of people with OA with this type of inflammation,” he adds.
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