Reumatología II

5ta sesión

Manejo en osteoartritis

MR2 Paul Jesus Tejada Llacsa

• Evidencias de manejo
• Manejo no farmacológico
• Manejo farmacológico
Manejo no farmacológico
Thomas S, Browne H, Mobasheri A, et al. What is the evidence for a role for diet and nutrition in osteoarthritis?
Rheumatol (United Kingdom) 2018; 57: iv61–iv74.
País Muestra Población Diseño Fitoquimico Resultado
EEUU 640 Adultos sin Transversal B-caroteno Progresión de OA radiográficamente se
problemas en asocio negativamente con ingesta
rodillas Efecto NS en incidencia de OA
radiográfico
Australia 293 Sanos Transversal Carotenoides Efecto NS de volumen de cartílago tibial,
área de hueso en el platillo tibial ,
defectos de cartílago, lesiones en medula
ósea
Australia 214 Sanos Transversal Carotenoides Prevalencia defecto de cartílago de
cabeza femoral se asocia negativamente a
la ingesta de luteína, zeaxantina, licopeno
Korea 57688 Adultos >50 a Transversal Carotenoides Efecto NS en la severidad de dolor de
rodilla

Adaptado de : Guan VX, Mobasheri A, Probst YC. A systematic review of osteoarthritis prevention and management
with dietary phytochemicals from foods. Maturitas 2019; 122: 35–43.
País Muestra Población Alimento Calidad de vida y dolor
EEUU 17 Obeso , OA rodilla Fresas ↓ ICOAP
↓ HAQ-DI
Efecto NS VASPAIN y VAS HEALTH
Iran 38 OA rodilla Jugo de granada Efecto NS en puntaje WOMAC
Canada 46 OA rodilla Planta de menta Efecto NS en puntaje WOMAC
verde
EEUU 53 OA rodilla Mezcla de jugo de Efecto NS en puntaje WOMAC
cereza agria y
manzana
EEUU 88 OA rodilla, o dolor Proteína de soya Efecto NS de actividades físicas de la vida
crónico en rodilla diaria, nivel de dolor
autoreportado

ICOAP: intermittent and constant osteoarthritis pain, HAQ-DI: health assessment quetionnaire disability index, VAS: visual
analog score , WOMAC western Ontario and McMaster Universties Osteoarthritis Index

Adaptado de : Guan VX, Mobasheri A, Probst YC. A systematic review of osteoarthritis prevention and management
with dietary phytochemicals from foods. Maturitas 2019; 122: 35–43.
Doherty M , et al. Oxford textbook of Osteoarthritis and Crystal arthropaty . Thrid edition.Chapter 31.2016. p306
Libro de texto de Oxford de OA mas artropatía por cristales
 Modalidades de terapia física
Intervención Evidencia Recomendación
Terapia manual Baja calidad de evidencia de efecto positivo a Considerar un curso corto como
corto plazo en función y dolor adyuvante en ejercicio físico , si el
paciente encuentra beneficioso
Modalidades térmicas Baja calidad de evidencia de efecto positivo a Considerar el uso de paquetes calientes
corto plazo en función y dolor o fríos como estrategia de automanejo

Electroterapia Baja calidad de evidencia de efecto positivo a Considerar el uso de TENS como
corto plazo en función y dolor de TENS estrategia de automanejo
Evidencia limitada en otras electroterapias

Inmovilizador de Limitada , baja calidad de evidencia que no No recomendado en OA

rodilla presenta efecto en dolor o funcion

Adaptado de : Rice D, McNair P, Huysmans E, et al. Best Evidence Rehabilitation for Chronic Pain Part 5:
Osteoarthritis. J Clin Med 2019; 8: 1769.
Intervención Evidencia Recomendación

Bastón Limitada, baja calidad de efecto positivo Considerar uso si lo encuentra

beneficioso
Tirantes suaves Baja calidad de evidencia que tenga efectos Considerar uso si lo encuentra
mixtos en dolor y función en OA rodilla beneficioso
Cabestrillo Baja evidencia de efecto positivo en OA de Considerar uso en OA de pulgar (>3
pulgar meses)
Calzado Limitada, baja calidad de evidencia que un tipo No recomendado en OA
especial sea mejor que el estandar
Plantilla de zapatos Baja calidad de evidencia en OA rodilla lateral Considerar en OA rodilla medial
Resultado mixtos en OA rodilla medial

Adaptado de : Rice D, McNair P, Huysmans E, et al. Best Evidence Rehabilitation for Chronic Pain Part 5:
Osteoarthritis. J Clin Med 2019; 8: 1769.
Page CJ, Hinman RS, Bennell KL. Physiotherapy management of knee osteoarthritis. Int J Rheum Dis 2011; 14: 145–151.
Efecto placebo en OA

Zhang W. The powerful placebo effect in osteoarthritis. Clin Exp Rheumatol 2019; 37: 118–123.
Zhang W. The powerful placebo effect in osteoarthritis. Clin Exp Rheumatol 2019; 37: 118–123.
Zhang W. The powerful placebo effect in osteoarthritis. Clin Exp Rheumatol 2019; 37: 118–123.
Guías de manejo no farmacológico de OA
 • Programas supervisados de ejercicios de fortalecimiento muscular
isocinéticos, isotónicos e isométricos
• Programa de ejercicio progresivo, educación y cuidados habituales.
• Programas de ejercicios de fortalecimiento de alta y baja resistencia.
• Programas de ejercicios con y sin soporte de peso
• Programa de ejercicios para fortalecer los cuádriceps
• Fisioterapeuta domiciliario programa para fortalecer los cuádriceps
• Programa de ejercicios de diagnóstico y terapia mecánica

Brosseau L, Taki J, Desjardins B, et al. The Ottawa panel clinical practice guidelines for the management of knee
osteoarthritis. Part two: Strengthening exercise programs. Clin Rehabil 2017; 31: 596–611.
Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis.
Osteoarthr Cartil 2019; 27: 1578–1589.
Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis.
Osteoarthr Cartil 2019; 27: 1578–1589.
Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis.
Osteoarthr Cartil 2019; 27: 1578–1589.
Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis.
Osteoarthr Cartil 2019; 27: 1578–1589.
Chavez JE, Zafra-Tanaka JH, Pacheco-Barrios K, et al. Guía de práctica clínica para el diagnóstico y manejo de la osteoartritis en el Seguro Social del
Perú (EsSalud). Acta Medica Peru 2019; 36: 235–246.
Manejo farmacológico
Drogas modificadoras de síntomas
• Analgésicos
• AINES
• Opiaceos
 AINES tópico

Dolor

Zeng C, Wei J, Persson MSM, et al. Relative efficacy and safety of topical non-steroidal anti-inflammatory drugs for osteoarthritis: A systematic review
and network meta-analysis of randomised controlled trials and observational studies. Br J Sports Med 2018; 52: 642–650.
 AINES tópico
• Funcionalidad

Zeng C, Wei J, Persson MSM, et al. Relative efficacy and safety of topical non-steroidal anti-inflammatory drugs for osteoarthritis: A systematic review
and network meta-analysis of randomised controlled trials and observational studies. Br J Sports Med 2018; 52: 642–650.
Puljak L, Marin A, Vrdoljak D, et al. Celecoxib for osteoarthritis. Cochrane Database Syst Rev. Epub ahead of print
2017. DOI: 10.12968/bjcn.2019.24.10.501.
Puljak L, Marin A, Vrdoljak D, et al. Celecoxib for osteoarthritis. Cochrane Database Syst Rev. Epub ahead of print
2017. DOI: 10.12968/bjcn.2019.24.10.501.
 Seguridad inhibidores COX-2

Curtis E, Fuggle N, Shaw S, et al. Safety of Cyclooxygenase-2 Inhibitors in Osteoarthritis: Outcomes of a Systematic Review and Meta-
Analysis. Drugs and Aging 2019; 36: 25–44.
• Cambio relativo en
dolor

Stewart M, Cibere J, Sayre EC, et al. Efficacy of commonly prescribed analgesics in the management of osteoarthritis: a
systematic review and meta-analysis. Rheumatol Int 2018; 38: 1985–1997.
• Cambio relativo en
dolor

Stewart M, Cibere J, Sayre EC, et al. Efficacy of commonly prescribed analgesics in the management of osteoarthritis: a
systematic review and meta-analysis. Rheumatol Int 2018; 38: 1985–1997.
Opiodes

Stewart M, Cibere J, Sayre EC, et al. Efficacy of commonly prescribed analgesics in the management of osteoarthritis: a
systematic review and meta-analysis. Rheumatol Int 2018; 38: 1985–1997.
Fuggle N, Curtis E, Shaw S, et al. Safety of Opioids in Osteoarthritis: Outcomes of a Systematic Review and Meta-Analysis.
Drugs and Aging 2019; 36: 129–143.
 Inyección intra-articular de corticoides-
rodilla

Jüni P, Hari R, Rutjes AWS, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev; 2015. Epub ahead
of print 2015. DOI: 10.1002/14651858.CD005328.pub3.
Jüni P, Hari R, Rutjes AWS, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev; 2015. Epub ahead
of print 2015. DOI: 10.1002/14651858.CD005328.pub3.
Jüni P, Hari R, Rutjes AWS, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev; 2015. Epub ahead
of print 2015. DOI: 10.1002/14651858.CD005328.pub3.
Jüni P, Hari R, Rutjes AWS, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev; 2015. Epub ahead
of print 2015. DOI: 10.1002/14651858.CD005328.pub3.
Jüni P, Hari R, Rutjes AWS, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev; 2015. Epub ahead
of print 2015. DOI: 10.1002/14651858.CD005328.pub3.
Saltychev M, Mattie R, McCormick Z, et al. The Magnitude and Duration of the Effect of Intra-articular Corticosteroid Injections on
Pain Severity in Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Am J Phys Med Rehabil 2020; 99: 617–625.
 Efectos adversos

Saltychev M, Mattie R, McCormick Z, et al. The Magnitude and

Duration of the Effect of Intra-articular Corticosteroid Injections on
Pain Severity in Knee Osteoarthritis: A Systematic Review and Meta-
Analysis. Am J Phys Med Rehabil 2020; 99: 617–625.
 Articulación trapeziometacarpal

Fowler A, Swindells MG, Burke FD. Intra-articular corticosteroid injections to manage trapeziometacarpal osteoarthritis—a systematic
review. Hand 2015; 10: 583–592.
Fowler A, Swindells MG, Burke FD. Intra-articular corticosteroid injections to manage trapeziometacarpal osteoarthritis—a systematic
review. Hand 2015; 10: 583–592.
 OA de cadera

McCabe PS, Maricar N, Parkes MJ, et al. The efficacy of intra-articular steroids in hip osteoarthritis: a systematic review. Osteoarthr Cartil 2016; 24:
1509–1517.
 Glucosamina/condroitín sulfato

Zhu X, Sang L, Wu D, et al. Effectiveness and safety of glucosamine and chondroitin for the treatment of
osteoarthritis: A meta-analysis of randomized controlled trials. J Orthop Surg Res 2018; 13: 1–9.
 diacerreína

Almezgagi M, Zhang Y, Hezam K, et al. Diacerein: Recent insight into pharmacological activities and molecular pathways.
Biomed Pharmacother 2020; 131: 110594.
 9%

Fidelix TSA, Macedo CR, Maxwell LJ, et al. Diacerein for osteoarthritis. Cochrane Database Syst Rev; 2014. Epub ahead of print
2014. DOI: 10.1002/14651858.CD005117.pub3.
Fidelix TSA, Macedo CR, Maxwell LJ, et al. Diacerein for osteoarthritis. Cochrane Database Syst Rev; 2014. Epub ahead of print
2014. DOI: 10.1002/14651858.CD005117.pub3.
Fidelix TSA, Macedo CR, Maxwell LJ, et al. Diacerein for osteoarthritis. Cochrane Database Syst Rev; 2014. Epub ahead of print
2014. DOI: 10.1002/14651858.CD005117.pub3.
 Extractos saponificables de avocado/soya

Simental-Mendía M, Sánchez-García A, Acosta-Olivo CA, et al. Efficacy and safety of avocado-soybean unsaponifiables for the treatment of hip and knee
osteoarthritis: A systematic review and meta-analysis of randomized placebo-controlled trials. Int J Rheum Dis 2019; 22: 1607–1615.
 Hialuronatos

Miller LE, Fredericson M, Altman RD. Hyaluronic Acid Injections or Oral Nonsteroidal Anti-inflammatory Drugs for Knee
Osteoarthritis: Systematic Review and Meta-analysis of Randomized Trials. Orthop J Sport Med 2020; 8: 1–11.
Miller LE, Fredericson M, Altman RD. Hyaluronic Acid Injections or Oral Nonsteroidal Anti-inflammatory Drugs for Knee
Osteoarthritis: Systematic Review and Meta-analysis of Randomized Trials. Orthop J Sport Med 2020; 8: 1–11.
 Guías de manejo farmacológico en OA

Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management
of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol 2020; 72: 220–233.
Chavez JE, Zafra-Tanaka JH, Pacheco-Barrios K, et al. Guía de práctica clínica para el diagnóstico y manejo de la osteoartritis en el Seguro
Social del Perú (EsSalud). Acta Medica Peru 2019; 36: 235–246.
Chavez JE, Zafra-Tanaka JH, Pacheco-Barrios K, et al. Guía de práctica clínica para el diagnóstico y manejo de la osteoartritis en el Seguro
Social del Perú (EsSalud). Acta Medica Peru 2019; 36: 235–246.
Doherty M , et al. Oxford textbook of Osteoarthritis and Crystal arthropaty . Thrid edition.Chapter 37.2016. p376
 Tratamiento dirigido a fenotipos clínicos

McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthri tis. Osteoarthr Cartil 2014; 22: 363–388.
Proyección de investigación
Terapia biológica

Grässel S, Muschter D. Recent advances in the treatment of osteoarthritis. F1000Research; 9. Epub ahead
of print 2020. DOI: 10.12688/f1000research.22115.1.
 Inhibidores del oxido nitrico

Leonidou A, Lepetsos P, Mintzas M, et al. Inducible nitric oxide synthase as a target for osteoarthritis treatment. Expert Opin Ther
Targets 2018; 22: 299–318.
Terapia genética
Aplicación directa gen

Madry H, Cucchiarini M. Gene therapy for human osteoarthritis: Principles and clinical translation. Expert
Opin Biol Ther 2016; 16: 331–346.
Kim MK, Ha CW, In Y, et al. A Multicenter, Double-Blind, Phase III Clinical Trial to Evaluate the Efficacy and Safety of
a Cell and Gene Therapy in Knee Osteoarthritis Patients. Hum Gene Ther Clin Dev 2018; 29: 48–59.
Kim MK, Ha CW, In Y, et al. A Multicenter, Double-Blind, Phase III Clinical Trial to Evaluate the Efficacy and Safety of
a Cell and Gene Therapy in Knee Osteoarthritis Patients. Hum Gene Ther Clin Dev 2018; 29: 48–59.
Terapia celular
• Plasma rico en plaquetas
• Implante autólogo de condrocitos
• inyección de células mesenquimales
 Plasma rico en plaquetas –OA cadera

Berney M, McCarroll P, Glynn L, et al. Platelet-rich plasma injections for hip osteoarthritis: a review. Ir J Med Sci.
Epub ahead of print 2020. of the evidence
 Plasma rico en plaquetas OA rodilla

Hohmann E, Tetsworth K, Glatt V. Is platelet-rich plasma effective for the treatment of knee osteoarthritis? A systematic review and meta-
analysis of level 1 and 2 randomized controlled trials. Eur J Orthop Surg Traumatol 2020; 30: 955–967.
 Plasma rico en plaquetas OA rodilla

Hohmann E, Tetsworth K, Glatt V. Is platelet-rich plasma effective for the treatment of knee osteoarthritis? A systematic review and meta-
analysis of level 1 and 2 randomized controlled trials. Eur J Orthop Surg Traumatol 2020; 30: 955–967.
De Bari C, Roelofs AJ. Stem cell-based therapeutic strategies for cartilage defects and osteoarthritis. Curr Opin Pharmacol 2018; 40: 74–80.
Davies RL, Kuiper NJ. Regenerative Medicine: A Review of the Evolution of Autologous Chondrocyte Implantation (ACI)
Therapy. Bioengineering 2019; 6: 1–16.
Davies RL, Kuiper NJ. Regenerative Medicine: A Review of the Evolution of Autologous Chondrocyte Implantation (ACI)
Therapy. Bioengineering 2019; 6: 1–16.
Ha CW, Park YB, Kim SH, et al. Intra-articular Mesenchymal Stem Cells in Osteoarthritis of the Knee: A Systematic Review of Clinical
Outcomes and Evidence of Cartilage Repair. Arthrosc - J Arthrosc Relat Surg 2019; 35: 277-288.e2.
 Ingeniería de tejidos

Vinatier C, Guicheux J. Cartilage tissue engineering: From biomaterials and stem cells to osteoarthritis
treatments. Ann Phys Rehabil Med 2016; 59: 139–144.
Vinatier C, Guicheux J. Cartilage tissue engineering: From biomaterials and stem cells to osteoarthritis
treatments. Ann Phys Rehabil Med 2016; 59: 139–144.
• Estudios in vitro, ex vivo
• modelos experimentales
• estudios clínicos en OA
 Estudios en OA-in vitro

Johnson CI, Argyle DJ, Clements DN. In vitro models for the study of osteoarthritis. Vet J 2016; 209: 40–49.
 Modelo ex vivo

Cope PJ, Ourradi K, Li Y, et al. Models of osteoarthritis: the good, the bad and the promising. Osteoarthr Cartil 2019; 27: 230–239.
Cope PJ, Ourradi K, Li Y, et al. Models of osteoarthritis: the good, the bad and the promising. Osteoarthr Cartil 2019; 27: 230–239.
Cope PJ, Ourradi K, Li Y, et al. Models of osteoarthritis: the good, the bad and the promising. Osteoarthr Cartil 2019; 27: 230–239.
Cope PJ, Ourradi K, Li Y, et al. Models of osteoarthritis: the good, the bad and the promising. Osteoarthr Cartil 2019; 27: 230–239.
Cope PJ, Ourradi K, Li Y, et al. Models of osteoarthritis: the good, the bad and the promising. Osteoarthr Cartil 2019; 27: 230–239.
Cope PJ, Ourradi K, Li Y, et al. Models of osteoarthritis: the good, the bad and the promising. Osteoarthr Cartil 2019; 27: 230–239.
Cope PJ, Ourradi K, Li Y, et al. Models of osteoarthritis: the good, the bad and the promising. Osteoarthr Cartil 2019; 27: 230–239.
Ensayos de implementación de
intervenciones para OA.
McAlindon TE, Driban JB, Henrotin Y, et al. OARSI Clinical Trials Recommendations: Design, conduct, and reporting of clinical trials for knee osteoarthritis.
Osteoarthr Cartil 2015; 23: 747–760.
Lane NE, Hochberg MC, Nevitt MC, et al. OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hip osteoarthritis. Osteoarthr Cartil
2015; 23: 761–771.
Kloppenburg M, Maheu E, Kraus VB, et al. OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hand osteoarthritis. Osteoarthr Cartil
2015; 23: 772–786.
Kloppenburg M, Maheu E, Kraus VB, et al. OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hand osteoarthritis. Osteoarthr Cartil
2015; 23: 772–786.
GRACIAS