Journals watch: Osteoarthritis, HRT, back pain and bariatric surgery

The latest papers of interest to GPs on osteoarthritis and ultrasound, progestogens in HRT, identifying low back pain, bariatric surgery in overweight patients and alternatives for osteoarthritis

Breast cancer risk must always be discussed when considering HRT
Breast cancer risk must always be discussed when considering HRT

Painful osteoarthritis and ultrasound in diagnostics

Rheumatol 2014 doi: 10.1093/rheumatology/keu030

Many older patients have painful osteoarthritis (OA) of their knees. Plain X-rays are 'moderately associated' with pain. We have all seen patients who have complained about the pain, despite almost normal-looking X-rays, and were later told how severe their cartilage loss was.

Ultrasound is able to visualise to the entire joint - cartilage, bone and soft tissue - so does it provide more insight into the complex disease processes producing pain and hence a cheaper, quicker way of triaging patients for knee surgery than MRI?

The answer is no. In this neat study of 180 patients with OA of the knees, assessment of ultrasound features like synovial hypertrophy had no association with the patient's level of pain.

Progestogens in postmenopausal hormone therapy

Maturitas 2014; 77: 311-17

When discussing HRT with women wishing to try something to alleviate their postmenopausal symptoms, it is important to mention the breast cancer risk.

In women with an intact uterus, a progestogen must be added to the estrogen to avoid endometrial hyperplasia or cancer.

Evidence from trials such as the Million Women Study in the UK and the Women's Health Initiative in the US show five additional breast cancer cases per 1,000 women over five years with estrogen/progestogen HRT, compared to estrogen monotherapy.

Natural progesterone and dydrogesterone are associated with a lower risk of breast cancer compared with the other progesterones. In the Finnish and French E3N studies, dydrogesterone appears to have a lower breast cancer risk.

How to identify low back pain

Arch Phys Med

How useful it would be if there was a simple test for 'chronic back pain', other than the subjective evidence of the patient.

This small study of 33 normal and 33 chronic back pain patients measured the erector spinae muscles with ultrasound on maximal isometric lumbar extension. The independent variables included in the analysis explained 42% (P=.003) of the dependent variable variance.

This study has major design flaws. The ultrasound difference may be atrophy from disuse, or the back pain patients may be moving differently. Not something to order yet.

Bariatric surgery in overweight patients with diabetes

Lancet Diabetes Endocrinol 2014 doi:10.1016/S2213-8587

There is now accepted evidence that bariatric surgery improves glycaemic control in obese patients with type 2 diabetes.

NICE guidelines state that bariatric surgery should be offered to patients with a BMI of 35-40 plus conditions from being overweight, such as diabetes and obstructive sleep apnoea, those with a BMI of 40-50 with no other weight-related conditions or those with a BMI of 50 and over, as a first-line treatment.

This paper looks at 'overweight', BMI 25-30, patients with type 2 diabetes. It was an RCT of 51 patients receiving normal care and gastric band versus normal care. At two-year follow up, 52% of the gastric band group had achieved remission, with a fasting blood glucose <7mmol/L, two days after stopping medication for diabetes. Only 8% of the standard care group managed this.

Alternatives for osteoarthritis

Maturitas 2014; 77: 380-4

GPs and patients are looking for alternative therapy in OA, now the increasing risks of stroke, MI, major gastric bleeds and kidney failure with NSAIDs are better understood.

There are estrogen receptors in bone, cartilage, synovial membrane, muscle and ligaments, which explains why women can have problems after the menopause.

Selective estrogen receptor modulators (SERMs) seem to help cartilage, but in terms of decreased pain in women, and correlated with changes in bone biomarkers such as CTX-I and CTX-II. There are also studies in animal models showing that tamoxifen decreases cartilage damage.

SERMs carry an increased risk of DVT/pulmonary embolism and can have side-effects of hot flushes, but they decrease breast cancer risk by about 30%. Two newer SERMS, lasofoxifene and bazedoxifene, have a European but not a UK licence for postmenopausal symptoms; neither has a licence for OA.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

  • Dr Hope is a GP in Woodstock, Oxon, and a member of our team who regularly review the journals

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Review your patients who have OA of the knee and the investigations they had before surgery.
  • Review the practice protocol for prescribing HRT in light of the differences in breast cancer risk with different progestogens, and sequential versus combined.
  • Perform an audit of your type 2 diabetes patients by BMI. Consider referring the appropriate ones for gastric banding under local guidelines, when you next review them.

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