Revue du Rhumatisme Monographies最新文献

Osteoarthritis (OA) is one of the most disabling arthritic condition. Aging is a major risk factor and represent one of the three OA phenotypes currently identified, including mechanical or obesity-related osteoarthritis. In the very elderly, loss of function and pain due to osteoarthritis are primary concerns. Other conditions related to osteoarthritis are associated with aging, as malnutrition and sarcopenia. Management of osteoarthritis in the oldest old require a global evaluation and care. This evaluation emphasizes ethical concerns after a look at the cognitive impairment and functional disability, taking into account often-underestimated pain and stiffness. Assessment of muscular and nutritional parameters seem to be as important as the rheumatologic evaluation in this frail population. Symptomatic care is the best option in the impaired elderly whereas global care with a multidisciplinary approach is preferred in the frail population. Individualized decision making after global assessment is one of the specificities of the very elderly care because of the major risks of safety concerns, especially with pharmacological therapies.

The KHOALA (Knee and Hip OsteoArthritis Long term Assessment) cohort is a multi-regional cohort of 878 subjects with symptomatic knee and/or hip OA, representative of the general population, constituted from 2007 to 2009. It provides an accurate phenotyping of patients to study the evolution and predictive factors of OA. The evolution of hip and/or knee osteoarthritis is stable for the vast majority of patients and no groups have been identified that include patients showing rapid progression of osteoarthritis. These results are consistent with those of studies in the literature. However, 16 % of the patients included in the KHOALA cohort underwent arthroplasty at 5 years. This proportion is not negligible and still reflects some progression of osteoarthritis in these patients. The stability of the clinical trajectories found in our studies and in the literature could be explained by the fact that annual measurements may not be sufficient to reveal significant fluctuations. Quarterly or semi-annual measurements could therefore highlight the occurrence of relapses more easily, which could indicate a worsening of the disease. It is also the persistence of pain or reduced functional capacity that could play a major role in the decision regarding hip or knee replacement surgery. Finally, these subjects whose progression is substantial may not belong to a sufficiently large, and therefore, easily identifiable subgroup. Patients with the most severe symptoms were more likely to be female, elderly, have a high body mass index, a high Kellgren & Lawrence stage, engage in low-intensity physical activity (PA), experience significant psychosocial distress and have a low vitality score. The impact of PA is modest in the cohort. It is the intensity and type of PA (weight-bearing activities or not) at inclusion that has an impact on physical function scores at 5 years. This effect is not mediated by body composition. The impact of co-morbidities in the clinical course is significant and is well reflected by its impact in the health care consumption of patients followed for osteoarthritis. The cohort, because it offers an accurate phenotyping of patients with a large and representative number of OA subjects in the general population, is a powerful means of studying the evolution of OA and its predictive factors.

The role of the intestinal microbiota within a “gut–joint” axis is increasingly studied in osteoarthritis. The intestinal microbiota, particularly via its role in low-grade systemic inflammation, could be involved in joint destruction and osteoarthritic pain. Its mechanisms of action in osteoarthritis remain complex, with, on the one hand, a direct action of intestinal dysbiosis on osteoarthritis involving systemic inflammation, and, on the other hand, an indirect effect via the promotion of metabolic syndrome and obesity. The published works in mice have mainly focused on the role of the intestinal microbiota in joint destruction in metabolic models of osteoarthritis. In humans, works have focused on indirect markers of the gut microbiota, such as lipopolysaccharide, or metabolites, such as tryptophan-derived ones. Also, intestinal dysbiosis could be one of the explanatory factors of osteoarthritic pain. A better understanding of the role of the intestinal microbiota in osteoarthritis could lead to the identification of new therapeutic targets.

The pharmalogical therapies currently available for the management of osteoarthritis are limited, either because of they have a modest effect-size, or because they can expose elder patients with often multiple comorbidities to a substantial risk of potentially dangerous side effects. The prevalence of osteoarthritis increases consistently, and there is therefore a major need for new treatments to treat the symptoms of osteoarthritis, but also to slow or stop the progression of the disease. The better understanding of the pathophysiology of osteoarthritis has led to the identification of new therapeutic targets, and some drugs related to these targets are currently being studied in phase 2 or 3 randomized controlled trials. These include anti-NGF antibodies, sprifermin, Wnt or cathepsin K inhibitors, some of which have shown promising results. Their long-term tolerance profile remains to be determined. Also, the benefit:risk ratio of anti-NGF antibodies, which induce rapidly progressive arthropathies, remains to be determined. These new treatments could, however, offer new therapeutic prospects for patients in the coming years.

To date, there is no specific treatment for osteoarthritis (OA). The difficulty in developing a therapy that is effective both symptomatically and structurally is due first to the significant delay in diagnosis linked to the long asymptomatic period and to a largely radiographic definition, therefore not identifying the earliest stages. But this is also linked to the pathophysiological complexity of OA disease (or syndrome), involving all joint tissues, a complex cellular dialogue and many inflammatory and catabolic mediators. The initiating pathogenic mechanisms, often overcome at the time of diagnosis, depend at least in part on the OA phenotype. Four main phenotypes are now identified: metabolic, genetic, traumatic and age-related OA. After drawing the epidemiological and semiological outlines of OA pathology, we will try in this review to summarize the main pathophysiological mechanisms.

Rapidly destructive osteoarthritis (RDOA) is considered as a rare and poorly diagnosed disease. RDOA is a destructive arthropathy that occurs most commonly in elderly women. The most typical radiological features are narrowing of the articular cartilage (chondrolysis) subchondral bone fracture, cysts in the femoral head/acetabulum, absence of osteophytes, flat femoral heads, and signs of joint effusion. RDOA was originally described in the hip but may also involve the shoulder and the knee. Pathogenesis is not well understood, but subchondral fracture probably plays a role in the development of destruction of the joint. Nevertheless, early diagnosis of the patients with rapid destructive arthritis of the hip is important to try to reduce complexity of surgical intervention.

Osteoarthritis (OA) is the most widespread rheumatism, involving up to 15 % of the adult population. The prevalence of osteoarthritis is increasing due to the aging of the population and the increasing incidence of obesity. Magnetic resonance imaging (MRI) provides an incomparable non-invasive evaluation of all joint structures. MRI is currently considered to be the most promising imaging modality for OA research providing a better understanding of the evolutionary processes and a more detailed analysis of the progression of OA disease. MRI imaging techniques, particularly via artificial intelligence, continue to step forward and will likely play a major role in the development of future OA therapies.

Pain is the main clinical manifestation of osteoarthritis. It is not simply a nociceptive message associated with joint destruction. In osteoarthritis, chronic pain is a disease in its own right, with several components: nociceptive, neuropathic and nociplastic. Assessment of pain intensity is a prerequisite. Adding self-questionnaires (DN4, ICOAP, OASIS…) makes it possible to screen for the different components of pain and to assess the patient experience. Ultimately, better phenotyping of osteoarthritic patients according to their pain would allow personalized treatment adapted to underlying pain mechanisms.

Many systemic autoimmune diseases and chronic inflammatory rheumatic conditions affect women of childbearing age. Pregnancy is most often possible, with generally acceptable fetal-maternal risks. So, pregnancy wish must be regularly sought and the optimal timing of pregnancy is essential. Women should be reassured that a good pregnancy outcome is generally possible if conception occurs in a stable remission state. The planification is ideally carried out during a preconception counseling appointment in order to look for possible contraindications (infrequent) and risk factors for obstetrical complications (previous obstetrical complication, antiphospholipid biology or syndrome, activity of the disease at conception, and definite organ failure) in order to optimize the management. The most frequent obstetrical complications are fetal losses and/or consequences of placental insufficiency. Anti-SSA and/or anti-SSB antibodies exposes to a low risk of fetal atrioventricular block. Adequate drugs adjustment should be done before conception to avoid an early relapse and to replace teratogenic drugs. Finally, organization of the follow up of this future pregnancy need to be defined in a multidisciplinary approach and explained to the patient at this time.