PROTEUS JOURNAL ISSN/eISSN: 0889-6348 Osteoarthritis and its treatment: A comprehensive review Akash Garg & Meenakshi Bajpai* Akash Garg: Institute of Pharmaceutical Research (IPR), GLA University, NH-2, Mathura- Delhi Road, Chaumuhan, Mathura, Uttar Pradesh (India), Pin – 281406 Meenakshi Bajpai: Institute of Pharmaceutical Research (IPR), GLA University, NH-2, Mathura-Delhi Road, Chaumuhan, Mathura, Uttar Pradesh (India), Pin – 281406 *Corresponding Author Prof. Meenakshi Bajpai Institute of Pharmaceutical Research (IPR), GLA University, Mathura NH-2, Mathura Delhi Road, Chaumuhan Mathura, Uttar Pradesh (India) Pin - 281406 Mob: +91 9811330854 Email: [email protected] VOLUME11 ISSUE 8 2020 http://www.proteusresearch.org/ Page No: 159 PROTEUS JOURNAL ISSN/eISSN: 0889-6348 Abstract Osteoarthritis is the most occurring disease today mainly in elderly patient which lead to inflammation and pain in joints. In this loss of elasticity occur due to change in the cartilage. According to different systems of medicine, there are different concepts of osteoarthritis. Ayurveda is one of the oldest systems of medicine used for treatment of chronic disorders like osteoarthritis. The other system includes unani and siddha concept. In unani system, the main cause of osteoarthritis is unbalanced state of mind and siddha system includes degeneration of articular cartilage in synovial joints. The allopathy concept of medicine is the most widely used nowadays which involve inflammation of joints due to activation of some enzymes like cyclooxygenase, lipoxygenase, interleukin etc. This review mainly focuses on the concept and treatment of osteoarthritis in different systems of medicine. Keywords: Osteoarthritis, Unani, Siddha, Ayurveda, Allopathy, cyclooxygenase. Introduction Arthritis is the common disease of joints which take place with the increase in age. In this, a person feels pain in joints and it most commonly take place in knee, hip, feet, spine etc. but it also occurs at finger, shoulder, wrist etc. People feel more pain in the cold and damp weather. It includes osteoarthritis, Rheumatoid arthritis, gout, ankylosing spondylitis, juvenile idiopathic arthritis, psoriatic arthritis, reactive, septic and thumb arthritis. Fig: Thumb arthritis[93] Osteoarthritis is the disease which may take place when the tissue which is covering the joints break down and these tissues provide support to the ends of the joints when joints move like walking, running etc. In this, people feel too much pain and it get worsen with the age and it affect millions of people worldwide. [1] VOLUME11 ISSUE 8 2020 http://www.proteusresearch.org/ Page No: 160 PROTEUS JOURNAL ISSN/eISSN: 0889-6348 Fig: Osteoarthritis[94] Rheumatoid arthritis is the auto-immune disorder in which the body attacks its own body joints and tissues. It is the most dangerous inflammatory disorder which can also affects our skin, heart, blood vessel etc. it mainly affects the joint’s lining which may result in the joint deformity and bone erosion. In severe condition, it can also cause disability of patient. [2] Fig: Rheumatoid arthritis[95] Gout is the disorder which can affect anyone at any age because it takes place when uric acid crystals deposits at the joints and cause intense pain and inflammation. The attack takes place suddenly even in the midnight also. The affected joint is swollen and hot. [3] Fig. Gout[96] Ankylosing spondylitis is a type of inflammatory disease in which some of the vertebrae of the spine of a person get fuse which make them less flexible and stiff and cause inflammation, pain and forward posture and if ribs get fuse or affected, then, a patient feels difficulty in deep breathing. [4] VOLUME11 ISSUE 8 2020 http://www.proteusresearch.org/ Page No: 161 PROTEUS JOURNAL ISSN/eISSN: 0889-6348 Fig. Ankylosing arthritis[97] Juvenile idiopathic arthritis is the disorder of children, as the name suggest juvenile (child with age below 18). So, this is a type of rheumatoid arthritis which most commonly take place in juvenile child. [5] Fig. Juvenile Idiopathic arthritis[98] Psoriatic arthritis is a type of arthritis which commonly takes place in people which has psoriasis (a disease in which person has red patches with silvery scales). The person having psoriasis when diagnosed they are also having psoriatic arthritis. [6] Reactive arthritis is a type of arthritis which take place due to triggering by the infection of other part of body like genitals, urinary tract intestine etc. It is also called as Reiter’s syndrome. [7] Fig. Reactive arthritis[99] VOLUME11 ISSUE 8 2020 http://www.proteusresearch.org/ Page No: 162 PROTEUS JOURNAL ISSN/eISSN: 0889-6348 Septic arthritis is the painful infection in joints which take place due to bacteria or viruses travelling in our body via blood stream or it can take place when any bacteria or virus enter directly into the joints by any injury. [8] Fig: Septic arthritis[100] Osteoarthritis Osteoarthritis is the joint pain disorder which affects 10% male and 18% female over the age of 60 years. The main risk factor for osteoarthritis is age. Change in the morphology of femoral and tibial bone can result in the development of knee osteoarthritis. If, there is the difference in the length of the legs, then, the chances of osteoarthritis are more in the shorter leg than the longer one. [9,10,11,12] Pathogenesis: Earlier, osteoarthritis is only known to be the disease of cartilage degradation but now it is known to be the disease which affect complete joint in which activation of matrix protease has main role. Synovium, cartilage and subchondral bone has the main role in pathogenesis of osteoarthritis. In osteoarthritis, synovitis is the most common feature. In this, synoviocytes’s proliferation and tissue hypertrophy with increasing vascularity takes place. [13] Cartilage contain a type II collagen which form a meshwork and it receive stabilisation from other collagen and non-collagen type protein and give tensile strength to cartilage. On activation, chondrocytes produce cytokines (IL6 and TNF) and matrix degrading enzyme (metalloproteinases) and these are having pathogenic effect. [1, 14] Subchondral bone forms a bridge between the cartilage and trabecular bone. A study showed that osteoblasts become active with the expression of inflammation responding agents. [15, 16] Development of osteoarthritis Level 1 – The matrix of cartilage breaks by proteolytic means. Level 2 – The surface of cartilage erodes and fibrillates and releases collagen & proteoglycan in synovial fluid. Level 3 – In synovium broken cartilage product causes chronic inflammation which further causes increase in cartilage breakdown. [83] VOLUME11 ISSUE 8 2020 http://www.proteusresearch.org/ Page No: 163 PROTEUS JOURNAL ISSN/eISSN: 0889-6348 Development of osteoarthritis Level 1 Level 3 Level 2 Fig: Development of osteoarthritis[83] Diagnosis Osteoarthritis can only be diagnosed if a patient has symptoms by imaging and biochemical markers. Traditionally, it is diagnosed by plain film radiography which includes the change in width of joint space, formation of osteophytes and subchondral cyst development. Now, MRI and ultrasonography are also used for imaging purpose. There are several biomarkers which are released during inflammation like cytokines and enzymes which degrade matrix. The concentration of these biomarkers can be measured synovial fluid, blood and urine also. There are other biomarkers also like CTX II and oligomeric matrix protein whose concentration can be measured in urine and serum respectively. [1] By using biochemical By using imaging Diagnosis markers Radiography Cytokines MRI Computed tomography Several enzymes Ultrasonography Bone scanning Fig: Diagnosis of osteoarthritis[1] Pain mechanisms in osteoarthritis Pain is the most common symptom which involves elevation of periosteal osteophytes, vascular blockage of subchondral bone, fatigueness in muscles, inflammation of synovial membrane which causes nociceptors activation, contracture and effusion of joints, swelling of synovial sac, tearing of VOLUME11 ISSUE 8 2020 http://www.proteusresearch.org/ Page No: 164 PROTEUS JOURNAL ISSN/eISSN: 0889-6348 tissue and psychological factors. In arthritis of lumbar spine, the region from L3 to L5 gets affected & its symptoms include radicular pain, spondylolisthesis. [83] Treatment: Osteoarthritis can be treated by change in the lifestyle like weight loss and exercise, surgery like joint distraction and periarticular osteotomy and NSAIDs like aceclofenac.[1] TABLE1: TREATMENT OF OSTEOARTHRITIS [1] Lifestyle modification Weight loss, exercise Symptom improvement and reduced risk of symptomatic osteoarthritis Surgery Debridement of FAI lesion Symptom improvement sustained beyond 5 years Joint distraction (6−12 weeks) Sustained symptomatic improvement with evidence of cartilage regeneration Regenerative surgical techniques Microfracture of subchondral Slight improvement in pain and bone defect filling Cell-based therapies1 Slight improvement in pain and defect filling Drug targeting Cartilage degradation Doxycycline108 Structural modification but no symptomatic benefit FGF-18 (intra-articular) Structural modification but no symptomatic benefit Drug targeting cartilage degradation Strontium ranelate Improvement in symptoms and structure Diagnosis in allopathy: [60,63,64] It can be diagnosed either by using biochemical markers or by using imaging techniques. 1) Normal radiography – It is the cost-effective method and give fast results. It shows the loss of space