16 Other body and mind therapies, such as yoga, tai chi and qi gong also can be used in OA treatment, with improvement evidences. 17 The use of drugs is to complement non-pharmacological procedures. Among the available drugs, there are those essentially analgesic drugs, that do not interfere in the course of the disease; as well as the anti-inflammatory drugs, controversial due table 5 to their side effects; and, finally, the drugs modifiers of the osteoarthritis disease (DMOOAD), those capable of reversing, stabilizing or at least delaying the course of OA. 5 Among DMOOAD of oral use diacerein 18 , glicosamine 19 , chondroitin 20 , the association of glucosamine with chondroitin 21 , the non-saponifiable extracts of soybean and avocado 22 and chloroquine are pointed out.
Glucosamine and chondroitin are, unquestionably, the most popular “chondroprotectors”. It has been recently discussed the relationship between the effectiveness of these substances and the type of used molecule, in addition to its isolated or associated use. Recent metanalysis 24 , as well as a Cochrane systematic review 19 reported benefits with the use of sodium glucosamine sulfate (Rotta type glucosamine) alone. A recent study also revealed that the chondroitin, when combined, can compromise the absorption of glucosamine. 25 Meanwhile, there is not yet consensus in the literature in this regard. Hyaluronic acid (HA) is an intra-articular DMOOAD, and its application is called visco-supplementation (VS). 26 It has an important modulating action, mainly through interaction with CD44 receptors present in type B “fibroblast-like” synoviocytes.
27 Therefore, besides the mechanical effect of promoting better distribution of forces, reduce the pressure due to weight and recovering the rheological properties of synovial fluid, hyaluronic acid also acts biochemically, reducing the gene expression of cytokines and enzymes associated from the OA. 27 From the economic point of view there is an increasing number of studies showing that, if incorporated into the treatment of knee OA, VS can be cost-effective, including being able to delay the completion of a total prosthetic knee. 28 Currently it is recommend the addition of 1 ml triamcinolone to visco-suplementation. 29 , 30 The addition of corticosteroids makes pain and function improvements occur earlier and in greater intensity, without compromising long term outcomes.
30 It is also possible to maximize the benefits of VS through a prior joint lavage. One should not wait for the failure of other treatment options to consider VS, since it is known that patients who will benefit most from this treatment are those whose disease is in early stage (lower grade OA) and use the joints more actively. 31 FINAL CONSIDERATIONS It is crucial to keep in mind that the treatment of OA is not scaled but multimodal. The patient should be educated about his disease and encouraged Carfilzomib to take an active behavior in his treatment.