#557 - New Osteoarthritis Treatment?, Water Bottle Safety, Just Be Kind
Take 3 – Practical Practice Pointers©
From the Literature
1) A New Treatment for Osteoarthritis?
A frustrating but common condition in primary care is osteoarthritis. Our medical options for treating this are limited: acetaminophen is frequently regarded by patients as ineffective, non-steroidal anti-inflammatory drugs (NSAIDs) can be toxic (especially at high doses for long treatment durations), and chronic opioid therapy for this condition is almost never a good option. Corticosteroid injections are frequently short-lived and often ineffective, and surgery is put off until the patient is both of older age and significantly disabled.
A familiar, but newly applied medical therapy has been tested for knee osteoarthritis (OA) – methotrexate (MTX). Usually used for rheumatologic conditions, methotrexate was subjected to a randomized, placebo-controlled trial for pain reduction in knee OA. From 15 clinical sites in the United Kingdom (UK), patients were solicited from both primary care and specialty care when their therapy for knee OA (acetaminophen, NSAIDs, or opioids) was deemed ineffective. Knee OA was diagnosed clinically using a locally read x-ray, and patients who had had steroid or hyaluronic acid injections or who had taken oral steroids recently were excluded. Patients were screened for rheumatologic disease using laboratory testing, and, if positive, were excluded.
Patients were randomized to oral MTX (dose escalating from 10 mg to 25 mg over six weeks) or placebo. Both groups of patients were given oral folic acid supplements. The patients were followed for 13 months, and a “rescue” intraarticular steroid injection was offered at six months if the pain was intolerable on medications. Pain was measured as a primary outcome at 6 months (and at baseline) by “average severity of pain out of 10 over the past week.” There were a slew of additional surveys and pain assessments administered as secondary outcomes.
One hundred fifty-five patients were randomized to MTX or placebo. Follow up percentage gradually declined over the 12 months to 78% - usually from quitting the study or from adverse events, but the loss was equal between groups. Both groups’ results on the pain rating scale decreased at 6 months, but the MTX group decreased by 0.8 points more (95% confidence interval (CI) 0.08 to 1.51; P < 0.030, which translates to a standard effect size of 0.34 or moderate). The benefit did not last until 12 months, and the authors postulate that the reduction in average MTX dose over the last six months of the trial (due to adverse events) could have caused the lack of benefit. There were scattered other significant differences amongst the scales used and the quarterly time points measured. There were no differences in analgesic use or radiologic changes. The authors made a point of stating that the main limitation was the choice not to allow subcutaneous injections of MTX to those that could not tolerate oral. This study was funded by “Versus Arthritis” – a UK charity organization for arthritis sufferers that sponsored arthritis research, but did not have a role in design, writing, or decision to publish the funded research.
John’s Comments:
Reading the abstract of this study, one gets the impression that MTX is a viable new therapy, and, while the study did achieve its primary outcome, the difference is rather small, and inconsistent across study time periods and scales. It could be that MTX finds a niche in non-rheumatologic arthritis, but for now, I would resist the urge to use this for OA pending more data.
Reference:
- Kingsbury SR, Tharmanathan P, Keding A, et al. Pain Reduction With Oral Methotrexate in Knee Osteoarthritis: A Randomized, Placebo-Controlled Clinical Trial. Ann Intern Med. Published online July 30, 2024:M24-0303. Link
From the Literature (sort of) and a Question From a Colleague
2) Resuable Water Bottle Hygiene
Question:
“Thank you for your recent Pointer on the health concerns regarding microplastics and nanoplastics. It was quite timely. I’m still left wondering about the safety of reusable water bottles. Not so much the metal from them as their cleanliness. Is there any information on that?”
Answer:
The reusable water bottle market reached approximately $2 billion in the US in 2023. They are a popular choice for health- and eco-conscious consumers, and based on our recent Pointer, would seem to be a safer choice than plastic disposable water bottles. However, their cleanliness is a concern if they are not properly maintained. Several studies have shown that reusable water bottles can harbor a variety of bacteria (including E. coli, Staphylococcus aureus, and Pseudomonas spp.), mold, and other microorganisms if they are not regularly cleaned. The primary sources of contamination are the user's mouth, hands, and environmental exposure. Bottles with spout-top and screw-top lids, narrow necks, and/or straws create the greatest risk for microbe contamination.
The International Association for Food Protection recommends washing bottles once a day with hot, soapy water, which surveys indicate is done by less than half of water bottle users. It is recommended to use a clean sponge or bottle brush to scrub the inside of the bottle, making sure to get deep into the crevices. Cleaning should occur more often if one drinks from it while eating or fills it with things other than water, like coffee or juice. Having a bottle with a filter does not appear to make a difference in terms of bottle contamination.
Some fun facts according to data from the website WaterFilterGuru.com:
- On average, a reusable water bottle has 40,000 times the bacteria of a toilet seat, 14x the bacteria of a pet water bowl, 5x the bacteria of a computer mouse, and 2x the bacteria of a kitchen seat.
- A straw-top water bottle has 14x the bacteria of a pet bowl
- A spout-top water bottle has 3x the bacteria of a kitchen sink.
- Gen Zers clean their bottles the least often, with 16% cleaning theirs only a few times a month.
Mark’s Comments:
While this is perhaps not the most “evidence-based” Pointer we’ve done, given that more than half of all adults in the US own a reusable water bottle (and growing), the topic is certainly a relevant one. Once a day cleaning of these bottles seems a wise habit in general, remembering, of course, that just because bacteria grow from these bottles does not mean they are pathogens.
Preparing this Pointer also provided me pause as I considered how often I wash the cup I use in our bathroom, or my toothbrush. Let’s just say it will happen more often going forward.
References:
From PeerRxMed ( www.PeerRxMed.org )
3) Leaving Them Better Than You Found Them – Just Be Kind
"Be kind whenever possible. It is always possible". The Dalai Lama
As he stood up to leave, he tearfully said, “You are so incredibly kind” and gave me a hug. We had just talked about a very sensitive health subject which had invoked for him both fear and shame and he was feeling the weight of the consequences of his actions. For my part, I listened, and both clarified some misinformation and offered some words of comfort and encouragement. I thought I had been an astute, thorough, insightful, caring, and even wise physician for him. “Kindness” was not on my radar. Yet there it was – “You are so … kind.”
It was intriguing to me that my initial internal reaction to his words was a surprising one. While I have no objection to being seen as kind, I don’t identify with it as one of my core professional attributes and realized in that moment that I’ve still not gotten past my professional (and perhaps gender) programming equating kindness with softness or weakness. But then I reconsidered as I recalled how many of my patient visits end with some tears, a “thank you,” and even a hug.
Now I was wondering, “What if kindness was one of the most immediately impactful therapies I could provide to those I care for?” After all, it can easily be expressed within the flow of patient care, transcends age, condition, and circumstance, and even in small “doses,” has the power to help not only hurting bodies, but emotional hurts as well. This "medicine" has the potential to reduce pain, alleviate anxiety, improve adherence, and promote a sense of well-being. And it can have positive therapeutic effects on the “prescriber” as well.
Indeed, there is evidence that kindness can change our physiology. Receiving kindness can decrease blood pressure and cortisol levels. Being kind has the potential to boost serotonin and dopamine, neurotransmitters that increase feelings of satisfaction and well-being. Brain imaging shows that expressing kindness can actually “light up” our pleasure/reward centers. Perhaps most importantly, kindness can stimulate the release of oxytocin, promoting a sense of bonding for both the giver and recipient.
Reflecting on my experience with that patient, I realize that the few minutes I spent connecting with him likely did more for his well-being than any prescription I could have given. This isn’t just a feel-good story, but a “help them feel better” story as well. When we engage meaningfully with others—patients, colleagues, or strangers—we contribute to a cycle of positivity. Next week, I’ll share some ideas as to how you can increase your KQ (“Kindness Quotient”), but in the meantime, consider taking this "KQ Quiz" to see what your baseline is. With this particular patient, I still think I was astute, thorough, insightful, caring, and even wise. But apparently I was also kind. And that, it appears, made all the difference.
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Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.
Email: mhgreenawald@carilionclinic.org