{"id":1134,"date":"2016-10-05T14:55:47","date_gmt":"2016-10-05T14:55:47","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1134"},"modified":"2017-08-21T10:47:40","modified_gmt":"2017-08-21T10:47:40","slug":"primary-care-corner-with-geoffrey-modest-md-symptomatic-knee-effusions-from-oa-resolve-with-spironolactone","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/05\/primary-care-corner-with-geoffrey-modest-md-symptomatic-knee-effusions-from-oa-resolve-with-spironolactone\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Symptomatic Knee Effusions from OA Resolve With Spironolactone?!"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>And so the wonder drug spironolactone seems to have another possible\u00a0indication: knee effusions from osteoarthritis (see\u00a0Elsaman AM. J Rheumatol 2016; 43: 1114).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>200 patients with unilateral knee effusion related to osteoarthritis (OA) based on clinical exam, ultrasound and synovial fluid analysis<\/li>\n<li>Mean age 51, 40% male,\u00a0weight 84 kg,\u00a0mean duration of effusion 16.5 days, mean thickness of fluid by ultrasound was 7.6 mm thick<\/li>\n<li>Randomized to 2 weeks of:\u00a0spironolactone 25 mg daily; ibuprofen 400 mg three times\/d; cold compresses twice a day, for 10 minutes each time; or placebo<\/li>\n<li>Assessment: effusion considered if &gt;4mm fluid; complete improvement if &lt;4mm, partial improvement if a\u00a0decrease but still &gt;4mm<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>At 2 weeks after treatment\n<ul>\n<li>Spironolactone group: <strong>66% had complete improvement<\/strong>\/20% partial\/14% no improvement; mean fluid thickness 3.7 mm<\/li>\n<li>Ibuprofen\u00a0group: 24% had complete improvement\/12% partial\/<strong>64% no improvement<\/strong>; mean fluid thickness 6.3 mm<\/li>\n<li>Cold compress\u00a0group: 28% had complete improvement\/14% partial\/58% no improvement; mean fluid thickness 5.9 mm<\/li>\n<li>Placebo\u00a0group: 6% had complete improvement\/10% partial\/84% no improvement; mean fluid thickness 7.3\u00a0mm<\/li>\n<\/ul>\n<\/li>\n<li>At 4 weeks after treatment\n<ul>\n<li>Spironolactone group:mean fluid thickness\u00a02.4\u00a0mm;\u00a0<strong>79% no recurrence of effusion<\/strong>\/21% recurrence<\/li>\n<li>Ibuprofen\u00a0group:\u00a0mean fluid thickness 5.1\u00a0mm;\u00a044% no recurrence of effusion\/<strong>56% recurrence<\/strong><\/li>\n<li>Cold compress\u00a0group: mean fluid thickness 5.0\u00a0mm;\u00a038% no recurrence of effusion\/62% recurrence<\/li>\n<li>Placebo\u00a0group:\u00a0mean fluid thickness\u00a06.9\u00a0mm;\u00a013% no recurrence of effusion\/88% recurrence<\/li>\n<\/ul>\n<\/li>\n<li>VAS (visual analog scale of pain, from 0-10):\n<ul>\n<li>Spironolactone group:at 2 weeks, decreased from 5.42 to 2.66, then at 4 weeks\u00a0to 1.06<\/li>\n<li>Ibuprofen\u00a0group:\u00a0at 2 weeks, decreased from 4.64 to 3.70,\u00a0then at 4 weeks\u00a0to 2.44<\/li>\n<li>Cold compress\u00a0group:\u00a0at 2 weeks, decreased from 5.16 to 4.00,\u00a0then at 4 weeks\u00a0to 2.53<\/li>\n<li>Placebo\u00a0group:\u00a0at 2 weeks, decreased from 5.14 to 4.50,\u00a0then at 4 weeks\u00a0to 4.00<\/li>\n<\/ul>\n<\/li>\n<li>Adverse effects of spironolactone: 8% had lowering of blood pressure, but not below normal; 6% had &#8220;disturbances in their sodium and potassium levels&#8221;, not otherwise elucidated.<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>About 45% of patients with painful knee OA have an effusion, increasing to 79% during activity in a European study;\u00a0another study\u00a0found effusion in\u00a055%<\/li>\n<li>In this study, <strong>NSAIDs were no better than placebo<\/strong>, though cold compresses were better than placebo<\/li>\n<li>Spironolactone was chosen because of its effect on other effusions (e.g. ascites, pleural effusion). Also, it does seem to have anti-inflammatory properties (aldosterone being pro-inflammatory). Other studies have found that spironolactone can improve muscle function in functionally-impaired elderly.<\/li>\n<li>Pretty striking response to spironolactone after only 2 weeks of therapy, with lack of recurrence at 4 weeks and\u00a0impressive continued decrease in effusion size. The VAS pain scale tracked with the effusion resolution, and continued to improve after therapy ended in all groups.<\/li>\n<li>One pretty significant problem with the study was that those on spironolactone were hospitalized for the first 3 days, to check the blood pressure every six hours. Not only is this questionably necessary, but it might well distort\/increase the &#8220;placebo effect&#8221; of the intervention.<\/li>\n<li>Another very recent article, a proof-of-concept study,\u00a0found\u00a0the opposite conclusion in elderly\u00a0Scottish\u00a0patients\u00a0(see McMurdo MET.\u00a0Arthritis Care &amp; Research 2016;\u00a068:716). Briefly:\n<ul>\n<li>86 community-dwelling elderly\u00a0patients\u00a0(all &gt;70 yo, with mean age of 77, 62% women) with symptomatic knee OA pain and radiologic OA, were\u00a0randomized to spironolactone 25 mg vs placebo for 12 weeks<\/li>\n<li>Result:\u00a0no difference in pain, stiffness or physical function\u00a0scores on WOMAC (Western Ontario and McMaster Universities Osteroarthritis Index)<\/li>\n<\/ul>\n<\/li>\n<li>I&#8217;m\u00a0not exactly sure why these outcomes are so different. But though both dealt with patients with symptomatic OA,\u00a0they are very different studies. The latter was older patients, no comment on whether effusion was present or not, 50% were on opiates, 66% on nonopioid preparations,\u00a0and 18% were\u00a0on\u00a0neuropathic drugs (amitriptyline, pregabalin, gabapentin). The study above, however,\u00a0was pretty much the opposite (younger patients with short-term\u00a0knee effusions and not on other meds, though they did not comment explicitly\u00a0on how often patients took any other meds during the 2-week study or in the month after the study)<\/li>\n<li>So, given the increasing indications and use of spironolactone over the past decade or more (resistant hypertension, hyperaldosteronism, heart failure, hirsutism,\u00a0&#8230;.) and that we in primary care in general are pretty comfortable using it and monitoring for safety, its short-term use in patients with symptomatic OA is appealing. I\u00a0think it is overall less toxic than many of the other meds we use (esp\u00a0NSAIDs), so it\u00a0might be reasonable to\u00a0consider. Larger and confirmatory\u00a0studies would be helpful prior to a stronger recommendation. My go-to therapy in most patients with symptomatic and functionally-impairing painful knee OA is still\u00a0steroid\u00a0knee injections for OA (really rapid response and ability to get back to their activities; a\u00a0local therapy, which\u00a0works almost all of the time, with\u00a0minimal systemic effects).<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Symptomatic Knee Effusions from OA Resolve With Spironolactone?! [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/05\/primary-care-corner-with-geoffrey-modest-md-symptomatic-knee-effusions-from-oa-resolve-with-spironolactone\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1134","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1134","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1134"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1134\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1134"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1134"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1134"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}