Unmet Needs for Treatment of Osteoarthritis of the Knee

Peter Salgo, MD: We’ve reviewed a whole bunch of treatment options for osteoarthritis. What are the unmet needs? We’ve got the operation. We’ve got these medicines. We’ve got physical therapy. What do people need that we’re not giving them or that we can’t give them?

Richard Iorio, MD: One large unmet need is having a disease-altering drug for osteoarthritis. We don’t have that yet. There are several in development. So, we’ll put that off to the side. The other unmet need is having evidence-based self-management tools for patients that don’t consume a lot of health care resources. These could help them cope with their arthritis while they’re going through the disease process and moving their way toward the time when they may need intervention, and could help them maximize their potential for an optimal result.

Peter Salgo, MD: So, you’re telling me that you’d like a magic drug, a magic bullet, to turn this disease off and perhaps even reverse it? We don’t have that.

Paul Lachiewicz, MD: Right. Someday, we may be able to do genetic profiling to determine who is at very high risk for getting osteoarthritis. And perhaps, we can counsel those patients not to play football, or do more water sports, or whatever.

Peter Salgo, MD: “No, I want to do everything that I want to do. I want to do it forever. I want no pain.” And, “I want it now. Right now.” Are there treatment options that are in the pipeline that offer some hope?

Andrew Spitzer, MD: I think we talked about a lot of them. To quote a good friend, “Local treatment for local disease really sort of underscores the desire for injectable treatments.” We talked about platelet-rich plasma and mesenchymal stem cells. These are things that are being studied. There’s a potential for things that we call SYSADOA [symptomatic slow-acting drugs for osteoarthritis] that may have some benefit. There are a lot of things on the horizon, in terms of these kinds of differential injections and the disease modifiers that are in the pipeline. All of these things are helpful. But, at this point, there’s nothing immediately on the horizon that’s going to change the game.

Peter Salgo, MD: Before we leave, I really want to go back to this last point that you brought up. Because there’s no cure, because it really hurts, and because what we have to offer is either invasive surgery or injections, and they still don’t necessarily make you 100%, this field is just sitting there ripe with the potential for abuse, with clinics that offer you the world and deliver nothing.

Paul Lachiewicz, MD: It’s sad to say that this is true, at least in my part of the country. They advertise regularly: “We’re going to get you back in the game, and get you doing your sports again.” Some of it is not realistic marketing.

Peter Salgo, MD: Do your patients come into your office saying, “Should I do this? Is it worth it?”

Richard Iorio, MD: All the time.

Andrew Spitzer, MD: Oh, yes. All the time.

Richard Iorio, MD: In competitive urban marketplaces, if they look hard enough, they’ll find someone to do any of these things. Sometimes, being reasonable with patients and not fulfilling their requests is seen as being unhelpful. But, we try and give them the evidence. We use mesenchymal stem cells for the treatment of osteonecrosis. But, we don’t feel it’s prime time for use in an arthritic joint. I don’t understand the mechanism of that.

There are other molecules in development, that we have in our labs, that are being geared toward certain biomarker profiles. They show a lot of promise. But, as you alluded to, systemic treatment for a local disease has a lot of harming effects, and we’ve seen that before. Pills to treat the inflammatory part of arthritis or the cartilage effects are going to affect all of your other organs as well. Those are very powerful drugs. They can be dangerous.

Peter Salgo, MD: It sounds like what the infectious disease people talk about every day—somebody with a viral infection who is demanding antibiotics because they want to get better right now. It makes no clinical sense, and it harms everybody. Does that sound analogous to you?

Paul Lachiewicz, MD: Yes. I would just like to go back to a point that I made. I would like to urge the primary care physicians not to prescribe opioids for patients with osteoarthritis of the knee. It’s not supported by any evidence, and it can eventually be very harmful to the patient.

Richard Iorio, MD: It makes it very difficult for us to get a successful result with a knee replacement.

Peter Salgo, MD: This has been a great discussion. You guys are amazing. When my knee goes out, I’m coming to one of you. But, unfortunately, we can’t turn back the clock. That’s something you were talking about, too.

Paul Lachiewicz, MD: Right.

Peter Salgo, MD: And so, with the little time remaining, I want to give each of you a moment to share a final thought with our viewers. Why don’t we start with you?

Richard Iorio, MD: I think that people have to realize that osteoarthritis is a manageable, lifetime disease. But, they have to take an active role in their own treatment and find the modulating entities that help them live their lives correctly. I think those tools are available out there. But, they have to use some common sense in what they pursue.

Peter Salgo, MD: And, your final thoughts?

Paul Lachiewicz, MD: Again, I can’t echo what Rich says enough. But, I think the treatment has to be lifestyle, doing the correct type of exercise, diet, and judicious medication.

Peter Salgo, MD: Do you know what this gives you? The last word.

Andrew Spitzer, MD: From my perspective, we’re all saying the same things. The way I say it to my patients is, “Your own God-given knees are the best ones you get.” As a great mentor of mine used to teach us, there isn’t anything that surgery can’t make worse. And so, you need to look at the management of osteoarthritis over a longitudinal period of the lifetime, and to try and choose the right thing, at the right time, for each right clinical scenario, and ultimately preserve your own joints until you’re a great candidate for joint replacement surgery.

Peter Salgo, MD: This has been a great discussion. Again, I want to thank all of you for being here. On behalf of our panel, I want to thank you for joining us. I hope you found this MD Magazine^® Peer Exchange^® discussion to be useful and informative. I’m Dr. Peter Salgo, and I’ll see you next time.

Transcript edited for clarity.