There are few reasons because of which osteoarthritis (OA) is so to say neglected by the Macedonian rheumatologist and  does not receive the same attention and care  such as rheumatoid arthritis.  

Assoc. Prof. Ljubinka Damjanovska-Krstikj 
Rheumatology Clinic Skopje, Macedonia  
University „‟Sv. Kiril I Metodij”, Skopje, Macedonia 

There are few reasons because of which osteoarthritis (OA) is so to say neglected by the Macedonian rheumatologist and  does not receive the same attention and care  such as rheumatoid arthritis.  
The first reason is the lack of time in the outpatient clinics where we mostly see patients with inflammatory arthritides and connective tissue diseases, because of which OA is considered as  less serious disease, which does not mean that it is not burdensome for the patients. There are no specialized clinics for OA patients. 
The second reason is  the use of the  outpatient software “Moj termin” which  does not allow us to spend enough time with the OA  patients to give them enough counseling: We are seeing almost 30-40 patients in 6 hours which leaves us with  9 minutes per patient and again less or  no  time for OA patients. We are limited to writing the prescriptions and giving intraarticular injections in a hurry.  
Patient‟s  education has to be left to the  family physicians who are not trained and  not motivated enough,  because of which our patients does not know the terms Body Mass Index and are still confused if they are  obese or not and what it adds to having OA. They still need lots of advices in order to make a difference between work activities and exercises and most of them think that exercises are even forbidden when they have OA.  
The third reason is the worldwide lack of OA biomarkers which can be used in everyday practice, the underuse of musculoskeletal ultrasound and the long lines for more sophisticated imaging techniques. Conventional radiography is still the most common method for the confirmation of the suspected diagnosis of OA after the clinical examination. 
The fourth reason is there is obviously no cure for OA and we usually treat only pain with NSAIDs, acetaminophen and opioids. The implementation of OARSI  treatment guidelines is not going easy.  The rheumatologist and especially the other specialties are not sure what to do with „uncertain‟ recommendations and sometimes use treatments which are so called „not appropriate‟ when having nothing else to do about patients complaints.  
The patients are also confused with the question which  of the  glucosamine, chondroitin or combination to use and they are following the advices of the pharmacists, neighbors, advertisements and not the experience of the practicing rheumatologist. This treatment is still expensive for them, without any reimbursement from the Health Fund. There is a lack of local clinical studies with the available OA drugs to see their effect on our OA patients. 
In regards to the intra-articular injections, most of the times we use intra-articular corticosteroid injections because intra-articular hyaluronic acid (IAHA) injections are available for a very limited number of patients who can pay for them. Most of the times patients buy them from abroad and transport them to Macedonia in very inappropriate conditions. 
The last reason is that most of our patients have multi-joint OA with comorbidities, very difficult to treat (very limited number is with knee OA and no comorbidities) which brings disappointment both to the patients and to the practicing rheumatologist, implying  the need of a much stronger collaboration between the subspecialties including physical therapy and orthopedic surgery.  

References:  
1. Hochberg MC,  Altman RD, April KT et al. American College of Rheumatology 2012 recommendations for the use of non-pharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res  2012; 64 (4): 465-74. 
 
2. Zhang V, Nuki G, Moskowitz RV et al. OARSI recommendations for the management of hip and knee osteoarthritis Part III: changes in evidence following systematic cumulative update of research published through January  2009 Osteoarthritis Cartilage. 2010; 18 (4):476-499  
 
3. Wu D, Huan Y, Fan W. Efficacies of different preparations of glucosamine for the treatment of osteoarthritis: a meta-analysis of randomised, double-blind, placebocontrolled trials. Int J Clin Pract. 2013 Jun; 67(6):585-9.