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Diretriz Clnica sobre o cuidado da pessoa com Osteoartrose em Ateno Primria

Mrio Roberto Garcia Tavares

Introduo
Osteoartrite ou Osteoartrose uma doena articular crnica e degenerativa prevalente, motivo freqente de cuidados em ateno primria e fonte de desabilidade em idosos, especialmente a osteoartrose de joelhos e quadril. Baseado em um estudo de Framingham, a prevalncia estimada de 2 a 6% na populao adulta, e chega a 34 e 31% em mulheres e homens acima de 60 anos de idade. Na Espanha, um estudo semelhante mostrou uma prevalncia de 10,2% em adultos e atinge 33,7% das pessoas com 70 a 79 anos. (FRIAS, 2004). Embora os mecanismos da osteoartrose no sejam claramente compreendidos, os fatores de risco incluem idade, histria familiar, forma anormal das articulaes e certos tipos de trabalho e atividades. Os aspectos patognicos dominantes incluem reas de destruio da cartilagem associada a um aumento da atividade do osso subcondral e formao marginal de ostefitos. Os objetivos do tratamento da osteoartrose so controlar a dor em repouso ou movimento, preservar a funo articular e evitar a limitao fsica, alm de promover melhor qualidade de vida e autonomia quando possvel, bem como evitar os efeitos adversos das intervenes.

Estratgia de busca
Realizada busca na MEDLINE de estudos clnicos randomizados ou meta-anlises nos ltimos 10 anos (06/05/1996), com o unitermo osteoartrite, publicado em ingls, espanhol e portugus. "Osteoarthritis"[MeSH] AND (Meta-Analysis[ptyp] OR Randomized Controlled Trial[ptyp]) AND (English[lang] OR Spanish[lang] OR Portuguese[lang]) AND ("middle aged"[MeSH Terms] OR "aged"[MeSH Terms]) AND "humans"[MeSH Terms] AND ("1996/05/06"[PDAT] : "2006/05/06"[PDAT])] Tambm foi realizada busca nas bases de dados da Cochrane e citaes bibliogrficas de artigos de reviso, publicados a partir de 2000 em prestigiados peridicos de medicina (The New England Journal of Medicine, JAMA, The Lancet, British Medical Journal, Annals of Internal Medicine, Archives of Internal Medicine, American Family Physician, Mayo Clin Proceedings), em peridicos especializados nacionais e internacionais (Arthritis & Rheumatism; Journal of Rheumatology, Revista 1

Brasileira de Reumatologia), alm das diretrizes j publicadas pela Associao Mdica Brasileira. No foi realizado contato com especialistas focais em busca de artigos chave ou no publicados.

Critrios de incluso:
Estudos clnicos randomizados e meta-anlises de estudos clnicos randomizados do manejo de osteoartrite, de fase III e IV avaliando dor, funo, qualidade de vida, mortalidade, necessidade de interveno cirrgica ou efeito adverso. (CHODOSH, 2005)

Critrios de excluso:
Os artigos foram revisados por ttulo e resumo (abstract) e foram excludos quando no se referiam ao manejo primrio da osteoartrite (2) e quando referentes a tcnicas cirrgicas (2), avaliao da segurana, tolerabilidade ou biodisponibilidade de medicamentos exceto quando comparou duas ou mais drogas (3), quando o desfecho no era orientado ao paciente (dor, funo, qualidade de vida, mortalidade). Seguimentos de menos de 8 semanas foram excludos se houvesse outro estudo clnico abordando a mesma questo (1). Quando o resumo no preenchia os critrios de excluso, o artigo completo foi avaliado. No foram includos artigos sobre tcnicas cirrgicas, pois fogem ao escopo dessa diretriz, a menos que comparassem interveno com manejo clnico. Um total de 744 artigos foram listados. Os artigos foram avaliados quanto validade interna de forma estruturada pelo autor e excludos quando houvessem falhas graves como perda de 20% dos sujeitos no seguimento, uso de desfechos no validados ou violaes importantes do protocolo.
Estudos de fase I e II Objetivo primrio no AO Tcnica cirrgica Segurana e Tolerabilidade DOE Menos de 8 semanas Total 744 52 132 105 11 59 78 280

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Diretriz
Sumrio das Recomendaes
Educao do paciente e, se possvel do cuidador, fisioterapia, atividade fsica, perda de peso em pacientes com sobrepeso e obesidade devem ser parte do manejo no farmacolgico da osteoartrose. Se disponvel oferea exerccios em classe, hidroginstica ou tai chi. Para pacientes com osteoartrose leve podem usar paracetamol 2 a 4 gramas por via oral ou se desejar terapias no convencionais. Se houver risco de lcera pptica considere inibidores da COX-2, caso contrrio utilize antiinflamatrios no seletivos, e paracetamol como resgate. Se o mdico for capacitado, metilprednisolona intra-articular uma opo eficaz e segura. Pacientes refratrios considere a adio de opiides ou derivados, uso de condroitina, acupuntura ou referncia ao especialista focal. Omeprazol, antagonistas H-2 em altas doses podem ajudar a prevenir lceras gastroduodenais, mas somente misoprostol mostrou ser capaz de prevenir hemorragia ou perfura

Intervenes no farmacolgicas
Educao e Auto manejo Atividades educativas so amplamente recomendadas e o envolvimento dos familiares no cuidado faz parte das linhas gerais de manejo de condies crnicas, mas existem relativamente poucas avalies dessas intervenes. Na maioria dos trabalhos analisados, poucos utilizaram desfechos validados e a maioria no foi capaz de mostrar resultados clinicamente relevantes a longo prazo, como mostrado na Tabela 1. No possvel concluir sobre o tamanho dos efeitos obtidos, mas educao no parece alterar a dor, embora melhore a funo articular (62,112), a rigidez matinal (62) e a autonomia (62, 112, 113). Automanejo da doena crnica pode ser definida como uma interveno sistemtica que direcionada ao paciente portador de doena crnica e que envolva auto-monitoramento ou processo de deciso (42). Nessa metanlise (Tabela 2) no foi possvel encontrar um efeito clnico relevante em relao dor, embora tenha significncia estatstica, assim como no estudo de Blixen e colaboradores (23). Heuts e colaboradores, estudando pacientes em Ateno Primria, encontraram uma diferena clinicamente relevante aos trs meses e que se manteve durante o segundo ano de estudo (98).

Tabela 1. Estudos Clnicos Randomizados sobre Intervenes Educativas


# 46 Estudo Cronan, 1998 Stio NE
1

Interveno Educao, suporte social ou ambos. Educao assistida por computador Educao, suporte social ou ambos.

Controle Cuidado usual

n 256

Durao 3 anos

Desfecho Primrio Avaliao global pelo paciente

Resultado NS; houve melhora em 1 a 2 anos

62 85

Edworthy, 1999 Groessl, 2000

Quadril e Joelho NR

Informao por computador Cuidado usual

252 363

8 semanas 3 anos

Uso apropriado da medicao Vrios desfechos sociomtricos

112

Keefe, 2004

Joelho

Treinamento do cuidador, exerccio, ou ambos Treinamento do cuidador e suporte educacional ao cuidador Educao do esposo

Cuidado usual

72

12 semanas

Condio fsica, questionrio de estratgia de enfrentamento e autoeficcia. Auto-eficcia, sofrimento emocional e estilo de lidar com a dor. Escala de medida do impacto da artrite (AIMS2) Questionrio de Avaliao da Sade (HQA) Depresso

No houve diferena quanto dor, mas teve uso apropriado da medicao e menor rigidez matinal. Todos melhoraram em 2 anos, mas no em 3. O resultado no melhora com o nmero de sesses atendidas. Suporte social: 1088,92 vs Educao 8435,65 vs Combinado: US$ 2.248,03 /QALY Funo foi melhor nos grupos com exerccio, e enfrentamento da dor foi melhor nos grupos com o treinador. Auto-eficcia foi melhor no grupo em que o cuidador foi treinado em comparao com o cuidado usual; Outros desfechos no mostraram diferenas estatsticas significativas. Casais compareceram em mdia 5,31 sesses (6 sesses previstas) No houve diferena entre os grupos para dor, desabilidade ou depresso, mas houve para auto-eficcia.

113

Keefe, 1996

Joelho

Cuidado usual

86

10 semanas

147

Martire, 2003

NE

Educao usual

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NE: No especificado; NR: No relatado; NS: No significativo; QALY: anos de vida ajustado por qualidade. ECR: estudo clnico randomizado; WOMAC: Western Ontario and Mc Master Universities Osteoarthritis Index, um escore tridimensional para dor, rigidez e funo

Tabela 2. Estudos sobre Automanejo


# 23 42 Estudo Blixen, 2004 Chodosh, 2005 Heuts, 2005 Stio NE NE Interveno Auto manejo Auto manejo Controle Cuidado usual Cuidado usual n 32 14
2

Durao 6 mese NE

Desfecho Primrio Aderncia e auto-eficcia WOMAC NS

Resultado

Meta-anlise de ECR. Diferena mdia -2 mm em uma escala visual de 100 mm 3 meses: -2.46 vs -0.53 (S) e sustentou-se at os 21 meses (S)

98

Quadril e Joelho

Auto manejo

Cuidado usual

273

21 meses

WOMAC

14 Estudos clnicos e no pacientes como os demais trabalhos.

Alimentao Chritensen e colaboradores, utilizando uma dieta de muito baixa caloria (cerca de 800 Kcal/dia) em pacientes com gonartrose, encontraram que 10% de reduo de peso resultam em 28% de melhora na funo articular, alm de reduo significativa da dor (43). Dieta associada a exerccios apresenta resultados na funo articular e autoconfiana na mobilidade melhor que essas intervenes isoladas, mesmo sem reduo significativa de peso (72). Messier e colaboradores (156-158) encontraram resultados semelhantes em 18 meses de seguimento, mas utilizando desfechos intermedirios. Seus resultados mostraram que para quilograma perdido, reduz-se 4,1 Kg de carga sobre o joelho. Complemento alimentar como vitamina E (29), gengibre (22), protena de soja (4) e metilsulfonilmetano (115) no resultaram em diferenas significativas na dor, funo ou qualidade de vida de pacientes com osteoartrose de quadril ou joelho. O uso de leo de soja/abacate apresentou resultados inconsistentes entre dois estudos: Maheu e colaboradores, em um estudo clnico randomizado multicntrico e duplo-cego, encontraram diferenas significativas aos seis meses para Escala Analgica Visual de dor e no ndice de Lequesne (141). Blotman e colaboradores estudando pacientes com osteoartrose de quadril e joelho por trs meses relataram somente menor uso de AINEs (24). Najm e colaboradores relataram que o consumo de adenosil metionina foi semelhante ao uso de celecoxib ao final de dois meses de acompanhamento (170). Fisioterapia Fisioterapia permanece como uma das pedras angulares no manejo da osteoartrose. Diversos estudos abordam essa questo em combinao ou no com intervenes educativas (16, 54, 77), individualmente ou em classes (74), na clnica ou em casa (9) alm de se realizada ou no na gua (15). Embora as tcnicas aplicadas sejam variadas (66,75,87,100) e associadas a aplicaes como ultrasom ou estimulao eltrica de baixa voltagem (77,100), embora os trabalhos tenham dificuldades metodolgicas como tamanho da amostra e a quase impossibilidade de cegar os pacientes para a interveno, os resultados so consistentes. Qualquer que seja a tcnica ou mtodo parece haver melhora da dor, da funo, do desempenho em subir escadas ou caminhar no plano e na qualidade de vida, especialmente quando envolve atividade fsica. Prticas No Convencionais

Uma variedade de prticas alternativas ou complementares tem sido testada na osteoartrose e inclui fitoterapia (16, 41, 128) toque teraputico (61, 83), hipnose (78), relaxamento (8, 61, 78), bracelete magntico (89) e tai chi (90, 224). A maior parte desses estudos tem amostras muito reduzidas ou falhas metodolgicas, como desfechos no validados ou violaes no protocolo, que limitam sua interpretao. O estudo de Hartman (90) e colegas sobre tai chi, por exemplo, utilizou o controle temporal, tipo antes e depois, em 33 pacientes avaliando desfechos intermedirios como equilbrio e caminhar 15,24 metros. O estudo de Song (224) usa desfechos questionveis e o autor reconhece que a amostra (72 mulheres) pequena. O estudo do bracelete magntico mostrou resultados promissores, mas em um grupo que deveria receber braceletes com baixa emisso magntica eles foram inadequadamente montados e estavam emitindo ondas magnticas. Esse grupo teve resultado melhor que o grupo com bracelete falso, sem o emissor, sugerindo que existe um efeito analgsico. O estudo de Kimmatkar e colaboradores sobre Boswellia serrata (116), utilizando extrato da casca dessa rvore indiana, encontrou resultados positivos, mas sua escala de dor no validada, do mesmo modo que o estudo de Rein e colaboradores sobre p de uma espcie de Rosa canina (202). Chantre e cols (41) estudaram Garra do Diabo (Harpagophytum procumbens) na dose de 435 mg, 6 cpsulas ao dia, por 4 meses em 122 pacientes com osteoartrose de quadril e joelho com desfechos validados (WOMAC e ndice de Lequsne). Os resultados foram melhores que diacerena e houve menor incidncia de para-efeitos.

Analgsicos
Paracetamol Paracetamol est no topo da lista de medicamentos recomendados em diretrizes clnicas de osteoartrose (American College of Rheumatology, 2002; COIMBRA et al., 2002, AMB, 2003). A maioria dos trabalhos avaliados nessa diretriz permitiu o tratamento de resgate com paracetamol. Entretanto, existem muito poucos trabalhos clnicos bem conduzidos avaliando sua eficcia e efetividade em osteoartrose de qualquer grau. Foram recuperados apenas trs trabalhos. Case e colegas (40) comparam paracetamol com diclofenaco e placebo, Miceli-Richards e colegas (160) compararam apenas com placebo, e Pincus e colegas (190) compararam a preferncia dos pacientes com relao a paracetamol, placebo e celecoxib. Miceli-Richards e colaboradores mostraram que paracetamol no foi eficaz em reduzir 30% da dor em pacientes com gonartrose em 6 semanas. Case e colegas tambm no mostraram melhora significativa em at 12 semanas. Comparado a placebo, diclofenaco foi eficaz em duas e 12 semanas. No trabalho de Pincus e colaboradores, paracetamol foi mais eficiente que placebo e inferior 7

ao celecoxib (190). Sua vantagem reside na baixa incidncia de efeitos adversos, que no foi diferente de placebo nos trs estudos. Temple e colaboradores estudaram a segurana e tolerabilidade do paracetamol comparado a naproxeno durante um ano em pacientes com osteoartrose (236). Apesar da aderncia ter sido baixa, pois somente 55 (19%) de 290 pacientes completaram o estudo, nenhum apresentou insuficincia ou disfuno heptica definida como elevao das enzimas hepticas acima de duas vezes os valores de referncia. Uma reviso da Chrocrane de 15 estudos clnicos randomizados (247) chegou s mesmas concluses: paracetamol melhor que placebo no controle da dor em repouso ou movimento, mas os resultados so modestos. inferior aos antiinflamatrios. Assim, paracetamol no recomendado como droga nica no manejo da osteoartrose, exceto quando a dor for leve ou quando houver contra-indicao aos outros tratamentos. Tramadol A diretriz do Colgio Americano de Reumatolgia (2002) no manejo da osteoartrose recomenda o uso de tramadol em pacientes que no tiveram a dor controlada adequadamente com paracetamol, antiinflamatrios no esterides (AINE) ou inibidors da COX-2. O potencial teraputico do tramadol na dor crnica deve-se ao seu mecanismo de ao singular, combinando aes noradranrgica, serotonergica e ao opiide leve. Dois trabalhos avaliaram formas de liberao controlada de tramadol comparada com placebo (7) e com inibidores da COX-2 (65). Utilizando o ndice de WOMAC, tramadol foi mais eficaz que placebo produzindo uma reduo da dor de 30,4 mm contra 17,7 mm, mas foi menos eficaz que inibidores da COX-2 (41,5 contra 48,3 mm). Efeitos adversos (sonolncia, nusea e constipao) representam limitao importante do seu uso, mas permanecem como opo em pacientes que no podem usar COX-2 ou AINE. Codena Markenson e colaboradores encontraram diferena significativa utilizando oxicodena de liberao prolongada 10 mg por via oral duas vezes ao dia no controle da dor em pacientes com osteoartrose sem resposta a outros tratamentos. Assim como tramadol, a limitao fica por conta dos efeitos adversos, com um nmero necessrio para dano (NNH) de 2,3 (145). Morfina

Caldwell e colaboradores avaliaram dose nica de morfina de liberao controlada, duas vezes ao dia e placebo em 295 pacientes com osteoartrose. Assim como tramadol, morfina foi mais eficaz que placebo, mas efeitos adversos semelhantes (sonolncia, nusea e constipao) ocorreram em 18 pacientes na morfina e apenas cinco no placebo. No houve diferena entre morfina uma ou duas vezes ao dia.

Antiinflamatrios No Esterides
Antiinflamatrios no esterides (AINE) esto bem estabelecidos no tratamento da osteoartrose. Diversas comparaes foram feitas com placebo, cuidado usual e entre antiinflamatrios, incluindo inibidores da COX-2: cido acetil-saliclico, cido tiaprofnico, diacerena, diclofenaco, etodolac, ibuprofeno, indometacina, nabumetona, naproxeno, niacinamida, oxaceprol, oxaprozin e piroxicam (10, 11, 13, 21, 67, 70, 80, 105, 124, 133, 165, 170, 171, 185, 214). A meta-anlise de Lee e colegas (129) resume bem os achados:
AINEs so estatisticamente superiores em reduzir a dor em repouso e ao caminhar comparado com paracetamol em osteoartrose sintomtica. Segurana, medida por descontinuao devido a efeitos adversos, no foi estatisticamente diferente entre os grupos tratados com AINE e paracetamol.

Embora estatisticamente significativos, os resultados so modestos, e variam de 10 a 30 mm em uma Escala Analgica Visual de 0 a100 mm. A maioria dos autores considera eficaz uma melhora de 30% dos valores em uma escala em relao aos seus valores iniciais, mas a maioria dos trabalhos na apresentam seus resultados dessa forma. No parece haver diferena entre os diversos antiinflamatrios quando comparados entre si, incluindo os inibidores da COX-2. Apesar da incidncia elevada de efeitos adversos, poucos estudos de longo prazo foram encontrados sobre a segurana dos antiinflamatrios no esterides. Scott e colaboradores, em um estudo clnico randomizado multicntrico de 812 pacientes portadores de gonartrose, por 5 anos utilizando indometacina ou cido tiaprofnico, encontraram uma taxa de efeitos adversos algo superior ao placebo: 63, 61 e 51% respectivamente. Ocorreram ao longo do estudo somente 3 casos de sangramento gastroduodenal. Os eventos adversos cardiovasculares contaram 6% para o indometacina, 3% para o cido tiaprofnico e 3% para o placebo. A mdia de idade desses pacientes era de 61 anos na poca da randomizao, e, como esperado em um estudo de longo prazo, houve um bom nmero de abandonos, embora similar entre os trs grupos (214).

Antiinflamatrios inibidores da COX-2


Diversas estudos compararam diferentes doses de inibidores da COX-2 com placebo, paracetamol e AINEs no seletivos: aceclofenaco, nimesulida, celecoxib, etoricoxib, lumiracoxib, meloxicam, rofecoxib, valdecoxib, meloxicam e lornoxicam (17, 39, 48, 53, 55, 56, 63, 64, 68, 71, 79, 81, 82, 84, 93, 94, 114, 118, 119, 120, 121, 125-127, 130, 132, 136, 140, 143, 148, 165, 179, 182, 184, 190, 210, 212, 219-222, 228, 234, 252, 260-262, 264, 267, 270). Os resultados so consistentes entre os diversos estudos, sendo esses agentes mais eficazes que placebo e paracetamol, e to eficazes quanto os AINEs no seletivos. Apresentam uma taxa semelhante de efeitos adversos, mas menos efeitos gastrointestinais. Doses altas desses agentes no so melhores que doses intermedirias, e, em geral, apresentam mais efeitos adversos. Alguns poucos estudos so de mdio prazo, sendo a maioria de curto prazo, isto , menos de seis meses (WALKER-BONE, 2006), e nenhum estudo foi de longo prazo, ou seja, dois anos ou mais. Portanto, pelos critrios usados nessa diretriz, no houve estudo mostrando efeitos adversos cardiovasculares. Esses efeitos foram demonstrados em estudos de ps-comercializao e em estudos de preveno de adenomatose polipide de clon, cujo seguimento foi de 3 anos, mostrando maior risco de infarto do miocrdio e acidente vascular cerebral. (BENNET et al., 2005) Assim, o risco de eventos cardiovasculares indesejveis no pode deixar de ser mencionado. Alm disso, antiinflamatrios no seletivos e inibidores da COX-2 elevam os nveis de presso sistlica em mdia 2,83 (1,34) mmHg e 3,85 (1,06) mmHg, respectivamente, e so desencorajados em pacientes com hipertenso no controlada (AW et al., 2005). Nos pacientes com hipertenso controlada, recomenda-se monitorar a tenso arterial com maior freqncia. Inibidores da COX-2 so contra-indicados em doena cardaca isqumica, doena cerebrovascular, doena arterial perifrica, insuficincia cardaca grave ou moderada (Mamdani et al., 2004). Antiinflamatros devem ser usados com cautela em idosos, em doenas alrgicas, durante a gravidez, a amamentao e se h transtornos da coagulao. So tambm contra-indicados quando presente histria de hipersensibilidade a cido acetil-saliclico (AAS), a outros antiinflamatrios no esterides, e naqueles em crise de asma, ou com histria de angioedema, urticria ou rinite precipitada por AAS ou AINEs. O uso de famotidina, um antagonista H-2, em altas doses (80 mg) mostrou-se efetivo na preveno de lcera gastroduodenal em pacientes recebendo antiinflamatrios no esterides por longo prazo (230). Uma reviso sobre a preveno de leso gastroduodenal induzida por antiinflamatrios

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afirma que omeprazol e antagonistas H-2 em altas doses podem prevenir ulceraes gastroduodenais. Entretanto, estudos clnicos demonstram que somente misoprostol foi capaz de prevenir complicaes srias como hemorragia e perfurao (Ardizzone, 1996).

Corticosterides intraarticular
Os resultados dos estudos sobre corticosterides intraarticular so algo discordantes e, pelo fato das intervenes diferirem entre si, quase impossvel fazer uma generalizao. Dos oito artigos recuperados sobre corticosterides intraarticular, 7 foram em gonartrose e apenas um em articulao metacarpofalangeana (155). Alguns autores estudaram associao com lavagem articular (76, 197 e 223) e um estudo comparou cido hialurnico com e sem corticosteride intraarticular (176). A maioria dos estudos mostra melhora da dor e funo nas primeiras 4 semanas, mas muitos falham em mostrar diferenas persistentes (76, 155, 197, 198, 223). interessante observar que Raynauld e colegas acompanharam ao longo de dois anos 68 pacientes com gonartrose submetidos a triamcinolona 40 mg intraarticular a cada 3 meses ou soluo salina (198). Os resultados no foram significantes para dor ou funo ao fim dos dois anos, mas a reduo do espao articular foi em mdia 0,05 mm no grupo da interveno comparado a 0,07 no controle, no significativa. Muito embora esse resultado deva ser interpretado com cautela, no refora a noo que corticosteride aumenta a degenerao articular. Uma meta-anlise de 36 estudos clnicos randomizados de curto prazo (16 a 24 semanas) sobre o uso corticosterides em gonartrose (5), mostrou um resultado favorvel com um risco relativo de 2,02 (IC 95%: 1,2-3,7) para a melhora dos sintomas, e sugere que doses altas (50 mg de prednisona) parecem ser mais efetivas. Assim, corticosteride intraarticular parece ser efetivo no manejo dos sintomas de pacientes com gonartrose, alm de seguro.

Agentes condroprotetores
Glucosamina Os resultados sobre o uso da glucosamina nos pacientes com osteoartrose so conflitantes. (33, 44, 49, 99, 102, 152, 181, 201, 206). Em um estudo clnico randomizado multicntrico duplo-cego com 6 meses de durao e uma amostra de 1583 pacientes, glucosamina associada a inibidor da COX-2 s foi eficaz no subgrupo de pacientes com osteoartrose severa (44).

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Uma reviso da Cochrane de 20 estudos clnicos randomizados, totalizando 2570 pacientes falhou em mostrar beneficio da glucosamina para dor, rigidez e funo articular em pacientes portadores de osteoartrose, embora os resultados no sejam uniformes e os autores no consigam explicar por que Os autores concluem que glucosamina no parece ser melhor que placebo, e to segura quanto. (246). Condroitina Os estudos sobre o uso da condroitina em pacientes com osteoartrose parecem ser superiores ao placebo (27, 34, 49, 150, 251,258) embora com resultados modestos. Condroitina no tem se mostrado superior aos antiinflamatrios no controle da dor e na manuteno da funo (44, 49, 166). Nossa estratgia de busca revelou apenas um artigo de longo prazo que estudou condroitina em pacientes com osteoartrose interfalangeana por trs anos, mas utilizou desfecho orientados doena, no caso do espao articular (258). Clegg e colaboradores sugerem que condroitina possa ter algum benefcio em pacientes com osteoartrose severa (44). Das e Hammad em um estudo semelhante no encontraram esse benefcio, mas a amostra era menor e pode no ter revelado esse efeito (49). No momento o uso da condroitina ainda no est bem estabelecido. Como condroitina parece ser uma droga segura (49, 250), pacientes com osteoartrose severa que no responderam a outras intervenes podem ter algum benefcio adicional. cido Hialurnico O uso de cido hialurnico intra-articular tem sido extensivamente estudado no tratamento da gonartrose. Nossa estratgia de busca revelou 16 estudos clnicos randomizados avaliaram diferentes variantes de cido hialurnico comparado a outras drogas e associado ou no a corticosteride intraarticular, fisioterapia e exerccio. Ou no mostraram significncia estatstica no controle da dor e na preservao da funo articular, ou mostraram resultados modestos (1, 2, 30, 52, 73, 109-111, 117, 131, 137, 187). Outros estudos mostram resultados significativos no controle da dor, na manuteno da funo e em desfechos relacionados qualidade de vida quando comparadas a placebo, como soluo salina, (35, 47, 104, 122, 139) ou comparada a cuidado usual (106), associado fisioterapia (12) ou corticosteride (176).

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cido hialurnico tem se mostrado uma droga segura, e sua aplicao no tem mostrado efeitos adversos importantes, limitando-se dor e reao local de menor monta (1, 2, 30, 47, 110, 122, 139). Em apenas um estudo houve reaes mais srias: vasculite e eritrodermia esfoliativa (104), muito embora em alguns estudos os efeitos adversos no tenham sido relatados (12, 73, 52, 109, 137, 187). Estudos posteriores de longo prazo so necessrios para estabelecer de forma mais consistente o papel do cido hialurnico no tratamento da gonartrose. Considerando que a aplicao desse medicamente dever ser realizada por profissional capacitado, recomendamos sua utilizao apenas em pacientes com gonartrose severa que no tenham respondido a outras intervenes.

Procedimentos
Pacientes com ostoeartrose progressiva que no responderam ao tratamento conservador e apresentam limitao funcional importante (atividades de vida diria, por exemplo) podem-se beneficiar de consulta com especialista focal para considerar procedimentos (Sociedade Brasileira de Reumatologia, 2003). Poucos estudos compararam tratamentos cirrgicos e conservadores. Estudos com lista de espera para interveno cirrgica permitem estimar a efetividade de algumas intervenes (18, 73). Artroscopia e irrigao articular Quatro estudos foram selecionados com nossa estratgia de busca sobre irrigao articular ou artroscopia no manejo da gonartrose. Em trs deles no houve diferena com placebo (28, 167), mesmo em estudos de longo prazo (108). Frias e colegas estudaram a adio de triamcinolona a lavagem articular e no encontram benefcio adicional (76). Outros procedimentos: Bandagem, Laser Alguns estudos tambm estudaram bandagem elstica (92) e laser (86, 175), mas so estudos limitados do ponto de vista metodolgico ou com amostras muito reduzidas, e no permitem emitir uma recomendao sobre essas tcnicas. Acupuntura Os estudos de acupuntura para pacientes portadores de gonartrose no mostraram melhora da dor, mas apresentaram melhora da funo (16,19), embora apresentam alguns problemas

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metodolgicos no cegamento e tambm perdas. Dois estudos de acupuntura em pacientes com osteoartrose de quadril mostraram resultados animadores (69, 91), mas so estudos limitados em amostra e tempo de seguimento para gerarem uma recomendao firme. Pacientes com osteoartrose de quadril que desejarem podem ser referidos para realizar acupuntura (B).

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Artigos Selecionados
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16. Bennell KL, Hinman RS, Metcalf BR, et al. Efficacy of physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Ann Rheum Dis. 2005; 64(6):906-12. 17. Bensen WG, Fiechtner JJ, McMillen JI, et al. Treatment of osteoarthritis with celecoxib, a cyclooxygenase-2 inhibitor: a randomized controlled trial. Mayo Clin Proc. 1999; 74(11):1095105. 18. Berggren M, Joost-Davidsson A, Lindstrand J, et al. Reduction in the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven year prospective study. Scand J Plast Reconstr Surg Hand Surg. 2001; 35(4):415-7. 19. Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2004; 141(12):901-10. 20. Berman BM, Singh BB, Lao L, Langenberg P, et al. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology (Oxford). 1999; 38(4):346-54. 21. Bjordal JM, Ljunggren AE, Klovning A, et al. Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials. BMJ. 2004; 329(7478):1317. 22. Bliddal H, Rosetzsky A, Schlichting P, et al. A randomized, placebo-controlled, cross-over study of ginger extracts and ibuprofen in osteoarthritis. Osteoarthritis Cartilage. 2000; 8(1):9-12. 23. Blixen CE, Bramstedt KA, Hammel JP, et al. A pilot study of health education via a nurse-run telephone self-management programme for elderly people with osteoarthritis. J Telemed Telecare. 2004; 10(1):44-9. 24. Blotman F, Maheu E, Wulwik A, et al. Efficacy and safety of avocado/soybean unsaponifiables in the treatment of symptomatic osteoarthritis of the knee and hip. A prospective, multicenter, threemonth, randomized, double-blind, placebo-controlled trial. Rev Rhum Engl Ed. 1997; 64(12):82534. 25. Bocanegra TS, Weaver AL, Tindall EA, et al. Diclofenac/misoprostol compared with diclofenac in the treatment of osteoarthritis of the knee or hip: a randomized, placebo controlled trial: Arthrotec Osteoarthritis Study Group. J Rheumatol. 1998; 25(8):1602-11. 26. Bookman AA, Williams KS, Shainhouse JZ. Effect of a topical diclofenac solution for relieving symptoms of primary osteoarthritis of the knee: a randomized controlled trial. CMAJ. 2004; 171(4):333-8. 27. Bourgeois P, Chales G, Dehais J, et al. Efficacy and tolerability of chondroitin sulfate 1200 mg/day vs chondroitin sulfate 3 x 400 mg/day vs placebo. Osteoarthritis Cartilage. 1998; 6(Suppl A):2530. 28. Bradley JD, Heilman DK, Katz BP, et al. Tidal irrigation as treatment for knee osteoarthritis: a sham-controlled, randomized, double-blinded evaluation. Arthritis Rheum. 2002; 46(1):100-8. 29. Brand C, Snaddon J, Bailey M, et al. Vitamin E is ineffective for symptomatic relief of knee osteoarthritis: a six month double blind, randomised, placebo controlled study. Ann Rheum Dis. 2001; 60(10):946-9. 30. Brandt KD, Block JA, Michalski JP, et al. Efficacy and safety of intraarticular sodium hyaluronate in knee osteoarthritis: ORTHOVISC Study Group. Clin Orthop Relat Res. 2001; (385):130-43. 16

31. Brandt KD, Mazzuca SA, Katz BP, et al. Effects of doxycycline on progression of osteoarthritis: results of a randomized, placebo-controlled, double-blind trial. Arthritis Rheum. 2005; 52(7):201525. 32. Brinkhaus B, Becker-Witt C, Jena S, et al. Acupuncture Randomized Trials (ART) in patients with chronic low back pain and osteoarthritis of the knee - design and protocols. Forsch Komplementarmed Klass Naturheilkd. 2003; 10(4):185-91. 33. Bruyere O, Pavelka K, Rovati LC, et al. Glucosamine sulfate reduces osteoarthritis progression in postmenopausal women with knee osteoarthritis: evidence from two 3-year studies. Menopause. 2004; 11(2):138-43. 34. Bucsi L, Poor G. Efficacy and tolerability of oral chondroitin sulfate as a symptomatic slow-acting drug for osteoarthritis (SYSADOA) in the treatment of knee osteoarthritis. Osteoarthritis Cartilage. 1998; 6(Suppl A):31-6. 35. Bunyaratavej N, Chan KM, Subramanian N. Treatment of painful osteoarthritis of the knee with hyaluronic acid. Results of a multicenter Asian study. J Med Assoc Thai. 2001; 84(Suppl 2):S57681. 36. Caborn D, Rush J, Lanzer W, et al; Synvisc 901 Study Group. A randomized, single-blind comparison of the efficacy and tolerability of hylan G-F 20 and triamcinolone hexacetonide in patients with osteoarthritis of the knee. J Rheumatol. 2004; 31(2):333-43. 37. Caldwell JR, Rapoport RJ, Davis JC, et al. Efficacy and safety of a once-daily morphine formulation in chronic, moderate-to-severe osteoarthritis pain: results from a randomized, placebocontrolled, double-blind trial and an open-label extension trial. J Pain Symptom Manage. 2002; 23(4):278-91. 38. Campbell R, Evans M, Tucker M, et al. Why don't patients do their exercises? Understanding noncompliance with physiotherapy in patients with osteoarthritis of the knee. J Epidemiol Community Health. 2001; 55(2):132-8. 39. Cannon GW, Caldwell JR, Holt P, et al. Rofecoxib, a specific inhibitor of cyclooxygenase 2, with clinical efficacy comparable with that of diclofenac sodium: results of a one-year, randomized, clinical trial in patients with osteoarthritis of the knee and hip: Rofecoxib Phase III Protocol 035 Study Group. Arthritis Rheum. 2000; 43(5):978-87. 40. Case JP, Baliunas AJ, Block JA. Lack of efficacy of acetaminophen in treating symptomatic knee osteoarthritis: a randomized, double-blind, placebo-controlled comparison trial with diclofenaco sodium. Arch Intern Med. 2003; 163(2):169-78. 41. Chantre P, Cappelaere A, Leblan D, et al. Efficacy and tolerance of Harpagophytum procumbens versus diacerhein in treatment of osteoarthritis. Phytomedicine. 2000; 7(3):177-83. 42. Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005; 143(6):427-38. 43. Christensen R, Astrup A, Bliddal H. Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthritis Cartilage. 2005; 13(1):20-7. 44. Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006; 354(8):795-808.

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45. Cochrane T, Davey RC, Matthes Edwards SM. Randomised controlled trial of the costeffectiveness of water-based therapy for lower limb osteoarthritis. Health Technol Assess. 2005; 9(31):iii-iv, ix-xi, 1-114. 46. Cronan TA, Hay M, Groessl E, et al. The effects of social support and education on health care costs after three years. Arthritis Care Res. 1998; 11(5):326-34. 47. Cubukcu D, Ardic F, Karabulut N, et al. Hylan G-F 20 efficacy on articular cartilage quality in patients with knee osteoarthritis: clinical and MRI assessment. Clin Rheumatol. 2005; 24(4):33641. 48. Curtis SP, Bockow B, Fisher C, et al. Etoricoxib in the treatment of osteoarthritis over 52-weeks: a double-blind, active-comparator controlled trial [NCT00242489]. BMC Musculoskelet Disord. 2005; 6:58. 49. Das A Jr, Hammad TA. Efficacy of a combination of FCHG49 glucosamine hydrochloride, TRH122 low molecular weight sodium chondroitin sulfate and manganese ascorbate in the management of knee osteoarthritis. Osteoarthritis Cartilage. 2000; 8(5):343-50. 50. Das SK, Mishra K, Ramakrishnan S, et al. A randomized controlled trial to evaluate the slowacting symptom modifying effects of a regimen containing colchicine in a subset of patients with osteoarthritis of the knee. Osteoarthritis Cartilage. 2002; 10(4):247-52. 51. Das SK, Ramakrishnan S, Mishra K, et al. A randomized controlled trial to evaluate the slowacting symptom-modifying effects of colchicine in osteoarthritis of the knee: a preliminary report. Arthritis Rheum. 2002; 47(3):280-4. 52. Day R, Brooks P, Conaghan PG, et al; Multicenter Trial Group. A double blind, randomized, multicenter, parallel group study of the effectiveness and tolerance of intraarticular hyaluronan in osteoarthritis of the knee. J Rheumatol. 2004; 31(4):775-82. 53. Day R, Morrison B, Luza A, et al. A randomized trial of the efficacy and tolerability of the COX-2 inhibitor rofecoxib vs ibuprofen in patients with osteoarthritis: Rofecoxib/Ibuprofen Comparator Study Group. Arch Intern Med. 2000; 160(12):1781-7. 54. de Jong OR, Hopman-Rock M, Tak EC, et al. An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip. Health Educ Res. 2004; 19(3):316-25. 55. Dequeker J, Hawkey C, Kahan A, et al. Improvement in gastrointestinal tolerability of the selective cyclooxygenase (COX)-2 inhibitor, meloxicam, compared with piroxicam: results of the Safety and Efficacy Large-scale Evaluation of COX-inhibiting Therapies (SELECT) trial in osteoarthritis. Br J Rheumatol. 1998; 37(9):946-51. 56. Detrembleur C, De Nayer J, van den Hecke A. Celecoxib improves the efficiency of the locomotor mechanism in patients with knee osteoarthritis. A randomised, placebo, double-blind and cross-over trial. Osteoarthritis Cartilage. 2005; 13(3):206-10. 57. Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2000; 132(3):173-81. 58. Dias RC, Dias JM, Ramos LR. Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee. Physiother Res Int. 2003; 8(3):121-30. 18

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Paciente com Osteoartrose

Medidas No farmacolgicas: Educao Educao do cuidador Exerccios Fisioterapia Perda de peso (se sobrepeso ou obesidade)

Se disponvel: Tai chi Hidroginstica Exerccio em classes

Persiste com dor? Sim OA leve No Sim Acrescente Inibidor da COX-2 Paracetamol como resgate Sim Paracetamol 2 a 4 gramas VO ao dia Terapias no convencionais

Risco para DUP No Acrescente AINE e Paracetamol como resgate

Persiste com dor? Sim Mdico capacitado em infiltrar a articulao? Sim Metilprednisolona intra-articular 34

Considere: Opiide ou derivado Condroitina Acupuntura Referncia para o reumatologista ou ortopedista

No