Pharmacist Intervention Can Help Improve Adherence to Treatment for Osteoarthritis in the Knee
Patients with knee osteoarthritis often don’t adhere to the treatment plan—for reasons that are easy to understand. It’s hard to stick with an exercise program when every movement causes pain, not to mention concern that activity may aggravate the pain and worsen joint degeneration. When it comes to medication, fears over adverse effects often lead to nonadherence.
One missing piece that makes a significant difference is simple communication, because patients tend to make decisions without a full understanding of the disease process or discussing medication concerns. Pharmacists are key communicators who can provide the information needed to improve adherence to treatment for osteoarthritis in the knee.
Knee Osteoarthritis Leads to Widespread Pain and Disability
Osteoarthritis affects 14 percent of all adults, with prevalence reaching 33.6 percent in those over the age of 65.1 Based on 2014 population statistics, that’s more than 15 million adults aged 65 and older who live with the pain and inflammation and who face a grim prognosis as osteoarthritis is the top cause of disability.2
An estimated 10 to 13 percent of the older adults develop osteoarthritis in the knee and the incidence is expected to rise due to the aging population and the ongoing obesity epidemic. Key information about knee osteoarthritis (OA) includes:
- Nearly half of those with knee OA have difficulty or are unable to climb 10 steps—they also struggle to walk just one-quarter of a mile.
- About 20 to 35 percent of cases of knee OA are genetically determined.
- Risk factors for knee OA include being overweight, joint injury, mechanical stress and estrogen deficiency.
As if the challenge of chronic pain and diminishing function wasn’t enough, the concern doesn’t stop there. Osteoarthritis doubles the risk of death from all causes. Meanwhile, the unrelenting knee pain and inflammation lead to centralized pain, which in turn crushes quality of life and makes patients more susceptible to cardiovascular disease and psychological disorders. Pharmacists can easily assess the risk for widespread pain because it’s directly associated with the severity of knee pain.3
Summary of Treatment Recommendations
Before you can support patient decisions, you’ll need to be familiar with the current treatment recommendations. With the possible exception of OTC pain relievers, adherence to all of them is low in patients with knee OA.
Nonpharmacologic recommendations – Foundational therapy for knee OA includes the following nonpharmacologic treatments:
- Weight loss if necessary
- Physical therapy
- Occupational therapy
- Hot-and-cold treatments
The type of activity chosen depends on the patient’s preference and ability to perform—the important goal is to stay active. Psychosocial interventions, walking aids, tai chi, and manual therapy supervised by a physical therapist are conditionally recommended by American College of Rheumatology (ACR) guidelines.4
Pharmacologic agents – Guidelines issued by the ACR in 2012 conditionally recommended using:
- Oral NSAIDs
- Intraarticular corticosteroid injections
- Topical NSAIDs such as diclofenac sodium 1.5 percent
- Intraarticular hyaluronate injections – in patients with inadequate response to first-line agents
Even though acetaminophen is included in the 2012 guidelines, research published in May 2016 found that single-agent paracetamol did not effectively relieve osteoarthritis pain.5 Pharmacists should also be aware that patients who rely on OTC pain relief products may take more than the recommended dose if pain isn’t relieved—whenever possible, counsel them about the serious health risks.
Why Patients Don’t Adhere to Treatment for Osteoarthritis in the Knee
It is unsurprising that out-of-pocket costs and concern for adverse effects are the top two reasons why patients stop their recommended pharmacological and nonpharmacological treatments. On the other hand, you may be a little stunned to learn that pain doesn’t drive adherence decisions—treatment factors have the biggest influence.
In addition to lack of knowledge about medication, a change in dosing regimen is another treatment-related red flag. One study reported that adherence dropped by 10 percent when the medical therapy changed from “as required” to “daily treatment.”6 While pharmacists routinely screen for medication interactions, you’ll help older adults with knee OA prevent complications related to polypharmacy by scheduling appointments for medication management.
The November 2016 issue of the Journal of Evaluation in Clinical Practice published a study that was small, yet still offers insight into patient perspectives.7 Interview results from 11 patients indicated that they were likely to stop taking medications when the following factors interfered:
- Disagreement with guidelines and recommendations
- Insistence on imaging
- Worry that physiotherapy would aggravate pain
- Perception that knee OA was not treated as a high priority health issue
- Bad experience with medications
- A limited understanding of the disease process
- Poor communication by health care professionals
Tips for Pharmacist Intervention
There’s no doubt that the most vital pharmacist intervention comes in the form of counseling about medications and simplifying the dosing schedule when necessary. But when you connect with patients to discuss medical therapy, ask about their nonpharmacologic treatment and take time to explain the role of activity for preventing disability. Consider including this information in your conversation:
- Early signs – Even before you dispense medications for knee OA, you may have the opportunity to talk with patients buying topical OTC products to relieve knee pain. Let them know that the earliest symptom of knee OA is pain when using stairs, and that if pain persists, they should visit their doctor.
- Exercise is not negotiable – Exercise is hard when patients are in pain, but knee pain is not a reason to avoid exercise. Resistance training and strength training are both recommended, but 85 percent of adults with knee OA do not get strength training.8
- Encouragement – Let them know that staying active is vital—knee OA patients who walk more than 6,000 steps daily maintain better overall function, according to presenters at the 2016 annual meeting of the American College of Rheumatology.9
- Refer to a physical therapist – Patients are very worried that exercise will make pain worse. They need to know that some pain during exercise isn’t always bad. At the same time, it’s hard for patients to know when to keep pushing versus when the level of pain means they should stop. Recommend they consult a physical therapist who can develop and supervise an appropriate and safe regimen.
- Assess for depression and social support – Psychosocial issues significantly influence adherence. Ask a few questions to determine how the patient is doing and whether they have any social support. If they’re depressed, suggest they talk to a mental health professional.
Patient Awareness and Education Encourages Better Adherence
Time and again, researchers have concluded that adherence improves when pharmacists are actively involved. That definitely holds true for patients with osteoarthritis, who see improvement in pain and function when pharmacists are on the medical care team.10 Your patients with knee OA require a lifetime of therapy and as your intervention promotes adherence, you can also help lower their risk for centralized pain, disability, and other chronic health conditions.
Pharmaceutica North America provides prescription drug products, OTC supplements that contain glucosamine and chondroitin, and active pharmaceutical ingredients that can be used topically and orally to relieve pain in patients with knee OA. Contact us today to talk about how we can support your pharmaceutical needs.
- “Osteoarthritis,” October 2015, https://www.cdc.gov/arthritis/basics/osteoarthritis.htm ↩
- “Aging Statistics,” May 2016, https://aoa.acl.gov/Aging_Statistics/index.aspx ↩
- “Knee Pain Severity Rather Than Structural Damage is a Risk Factor for Incident Widespread Pain: The Multicenter Osteoarthritis (MOST) Study, September 2016, http://onlinelibrary.wiley.com/doi/10.1002/acr.23086/full ↩
- “American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee,” April 2012, http://www.rheumatology.org/Portals/0/Files/ACR%20Recommendations%20for%20the%20Use%20of%20Nonpharmacologic%20and%20Pharmacologic%20Therapies%20in%20OA%20of%20the%20Hand,%20Hip%20and%20Knee.pdf ↩
- “Effectiveness of Non-Steroidal Anti-Inflammatory Drugs for the Treatment of Pain in Knee and Hip Osteoarthritis: A Network Meta-Analysis,” May 2016, https://www.ncbi.nlm.nih.gov/pubmed/26997557 ↩
- “Patient Preferences for Adherence to Treatment for Osteoarthritis: The Medication, Decisions in Osteoarthritis Study (MEDOS), May 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3660275/ ↩
- “Barriers for Guideline Adherence in Knee Osteoarthritis Care: A Qualitative Study from the Patients’ Perspective,” November 2016, https://www.ncbi.nlm.nih.gov/pubmed/27859970 ↩
- “Telephone Counseling for Long-Term Adherence to Strength Training for Knee Osteoarthritis,” April 2014, http://www.bu.edu/enact/files/2011/03/NARRTC-2013-TLC-Pilot-4-19-13-ENACT.pdf ↩
- “Knee OA No Excuse to Skip Out on Physical Activity,” November 2016, http://www.medpagetoday.com/MeetingCoverage/ACR/61515 ↩
- “Pharmacists on the Front Lines of Osteoarthritis Care,” September 2012, https://www.uspharmacist.com/weekly_news_update/story/36382 ↩