A 68-year-old man comes to the office due to right knee pain for the last several months. The pain is exacerbated by activity and occasionally associated with transient swelling but no warmth or fever. Medical history includes type 2 diabetes, hypertension, and hyperlipidemia. The patient was also diagnosed with gout 5 years ago when he had severe right foot pain, and it is treated chronically with low-dose allopurinol. He drinks 1 or 2 beers a day. Vital signs are normal. BMI is 32 kg/m². The right knee is not swollen or erythematous, but active range of motion elicits pain. Hemoglobin A1c is 7.3% and serum uric acid level is 5.2 mg/dL (normal: 3.0-8.2). Knee x-ray is shown in the exhibit. Which of the following interventions would provide the greatest long-term benefit for this patient's current symptoms?

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11ec25c8_d2c0_5657_bc81_6123661baf2e_MD0003_00 This patient has osteoarthritis (OA) of the knee with chronic joint pain that is worse with activity. The x-ray shows joint space narrowing at the patellofemoral compartment (bone on bone) with extensive osteophyte formation; knee OA classically affects the tibiofemoral joint, but the patellofemoral compartment may be involved as well. Risk factors for knee OA include age >40, obesity, abnormal joint alignment (eg, varus deformity), and prior joint injury. osteophyte formation Initial management of knee OA should include regular, low-impact aerobic activity (eg, walking, cycling) and weight loss, particularly in overweight and obese patients. Weight loss decreases the inflammation and joint loading that promote degeneration of the articular cartilage and is associated with decreased pain and functional impairment. There is a dose-response relationship between amount of weight lost and improvement in joint symptoms. Caloric restriction may contribute to loss of lean mass and therefore should be combined with muscle-strengthening exercises. Exercises to strengthen the quadriceps muscles can improve function and protect the articular cartilage from further stress. (Choice A) The benefits of acetaminophen in osteoarthritis are small and inconsistent and likely do not outweigh the adverse effects (eg, hepatotoxicity) for most patients. (Choice B) Alcohol intake is associated with the degradation of articular cartilage and worse OA symptoms. However, the effect of moderate alcohol use is relatively minor, and the benefits of an effective weight-loss program would have the greatest impact. (Choice C) Chronic hyperglycemia can accelerate the progression of OA, likely due to glycosylation of components of articular cartilage. However, this patient's hemoglobin A1c is only slightly elevated, and stricter diabetes control would likely have little effect on his OA. In addition, in elderly (age >65) patients, a target hemoglobin A1c of 7%-8% is generally recommended to avoid dangerous hypoglycemia. (Choice D) Allopurinol is used for prophylactic therapy in gout, which typically presents with acute attacks of redness, warmth, and swelling; it is not used for OA. In addition, this patient's uric acid level is <6 mg/dL, which is usually adequate to prevent gout attacks. Educational objective: Initial management of osteoarthritis of the knee should include regular, moderate activity and weight loss, particularly in overweight and obese patients. Weight loss decreases the inflammation and joint loading that promote degeneration of the articular cartilage and is associated with decreased pain and functional impairment. References: American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. (http://www.ncbi.nlm.nih.gov/pubmed/22563589)

A 68-Year-Old Man Comes to the Office Due to Right