Managing osteoarthritis: What’s best for your patient?

,

Applied Evidence

Managing osteoarthritis: What’s best for your patient?

J Fam Pract. 2008 October;57(10):644-649

By

Greg P. Gutierrez, MD

New guidelines rate the evidence for hip and knee OA treatments. Handy chart provides at-a-glance summary

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References

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5. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage. 2007;15:981-1000.

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8. Towheed TE, Hochberg MC, Judd MG, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2003;(2):CD004257.-

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Practice recommendation

Teach patients that self-care is key to successful management of osteoarthritis (Osteoarthritis Research Society International [OARSI] Evidence 1a
Encourage patients to regularly engage in aerobic, muscle-strengthening, and range-of-motion exercise (Ia: knee; IV: hip).
Recommend that patients try acetaminophen (≤4 g/d) before considering other analgesics for mild to moderate joint pain (Ia: knee; IV: hip).
Prescribe the lowest effective dose of nonsteroidal anti-inflammatory drugs (NSAIDs) and avoid using them for long-term therapy (Ia).

OARSI level of evidence:

Ia: Meta-analysis of randomized controlled trials (RCTs)
Ib: RCT
IIa: Controlled study without randomization
IIb: Quasi-experimental study
III: Nonexperimental, descriptive studies
IV: Expert committee reports/opinion/experience

Osteoarthritis (OA) and other rheumatic conditions account for as many office visits as cardiovascular disease or essential hypertension, according to national data, and most involve primary care physicians.¹ As the population ages, the prevalence of OA—estimated at 46.4 million in 2005 in the United States alone—will continue to rise.^2,3 So, too, will the number of patients needing treatment for pain and functional limitations related to OA of the hips and knees.

Physicians who treat these patients have a new tool at their disposal: the Osteoarthritis Research Society International (OARSI)’s evidence-based, expert consensus guidelines for the management of hip and knee OA. These recommendations, published in February 2008, are the first “internationally agreed and universally applicable guidelines for the management of these global disorders.”⁴

In caring for patients with OA of the hips or knees, family physicians should keep in mind 2 guiding principles at the heart of the OARSI recommendations:

FAST TRACK

Recommend acetaminophen (≤4 g/d) before other analgesics for mild to moderate joint pain

the importance of lifestyle modification, including regular exercise, in coping with this degenerative, potentially debilitating disease; and
the need to incorporate both nonpharmacologic interventions and drug therapy to achieve optimal care.⁴

International team sifts through the evidence

To develop the guidelines, OARSI convened a committee of 16 physicians from 6 countries and 2 continents, with expertise in 4 disciplines: rheumatology, orthopedics, evidence-based medicine, and primary care. The team reviewed national and regional guidelines and studied systematic reviews; meta-analyses; randomized controlled trials (RCTs); controlled and uncontrolled trials; cohort, case-control, and cross-sectional studies; and economic evaluations from 1945 through 2001. The team also conducted a systematic review of evidence from January 2002 through January 2006.^4,5 To ensure the quality of evidence hierarchy, the team used internationally accepted research tools.

AP and tunnel images are key to OA diagnosis

A diagnosis of knee or hip osteoarthritis (OA) requires a medical history; physical examination; radiologic assessment, with standing X-rays of the lower extremities, including anterior-posterior and tunnel views for knee OA; and the exclusion of other conditions.30 The tunnel view shown here reveals bone-on-bone articulation in the medial compartment of the left knee, and demonstrates the importance of standing X-rays.

Differential diagnosis includes gout, pseudogout, rheumatoid arthritis, patella-femoral pain, pes anserine (knee) bursitis, iliotibial band pathology, meniscal tear, cruciate tears, and tumors. No blood tests are indicated unless an inflammatory process is suspected. Synovial fluid in an osteoarthritic knee has a white cell count of <2000/uL.³¹

The team used several criteria to rate the recommended strategies, including level of evidence, effect size for pain relief, level of consensus, and strength of recommendation (SOR). All of these criteria are included (and defined) in an at-a-glance summary of the OARSI recommendations ( TABLE ).

In particular, the SOR, which is used throughout this article, is an overall rating that reflects the opinions of the team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. It is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.

TABLE
OARSI guidelines rate the evidence for osteoarthritis treatment options

RECOMMENDATION	*SOR, % (95% CI)/ LEVEL OF CONSENSUS, %^†**	LEVEL OF EVIDENCE^‡	ES (95% CI)^§
Nonpharmacologic
Education, self-help, patient-driven treatment	97 (95 to 99)/NA	Ia: education	NA
Aerobic, muscle-strengthening, and range-of-motion exercises	96 (93 to 99)/85	Ia: knee IV: hip Ib: hip, water-based	0.52 (0.34 to 0.70): aerobic 0.32 (0.23 to 0.42): strength 0.25 (0.02 to 0.47): water-based
Weight loss	96 (92 to 100)/100	Ia	0.13 (-0.12 to 0.38)
Walking aids	90 (84 to 96)/100	IV	NA
Physical therapy	89 (82 to 96)/100	IV	NA
Appropriate footwear/insoles	77 (66 to 88)/92	IV: footwear Ia: insoles	NA
Knee braces	76 (69 to 83)/92	Ia	NA
Telephone contact	66 (57 to 75)/77	Ia: knee; IV: hip	0.12 (0 to 0.24)
Thermal modalities	64 (60 to 68)/77	Ia	0.69 (-0.07 to 1.45)
Acupuncture	59 (47 to 71)/69	Ia	0.51 (0.23 to 0.79)
TENS	58 (45 to 72)/69	Ia	NA
Pharmacologic
Oral NSAIDs	93 (88 to 99)/100	Ia	0.32 (0.24 to 0.39)
Acetaminophen ≤4 g/d	92 (88 to 99)/77	Ia: knee; IV: hip	0.21 (0.02 to 0.41)
Topical NSAIDs/capsaicin	85 (75 to 95)/100	Ia	0.41 (0.22 to 0.59)
Weak opioids/narcotics	82 (74 to 90)/92	Ia	NA
IA corticosteroid injections	78 (61 to 95)/69	Ia: knee; Ib: hip	0.72 (0.42 to 1.02)
IA hyaluronate injections	64 (43 to 85)/85	Ia	0.32 (0.17 to 0.47)
Glucosamine and/or chondroitin	63 (44 to 82)/92	Ia: glucosamine	0.45 (0.04 to 0.86)
Surgical treatments
Joint replacement	96 (94 to 98)/92	III	NA
Unicompartmental knee replacement	76 (64 to 88)/100	IIIb	NA
Osteotomy/joint preservation	75 (64 to 86)/100	IIb	NA
Joint fusion	69 (57 to 82)/100	IV	NA
Joint lavage/arthroscopic debridement	60 (47 to 82)/100	Ib	0.09 (-0.27 to 0.44): lavage -0.01 (-0.37 to 0.35): debridement
CI, confidence interval; ES, effect size for pain relief; IA, intraarticular; NA, not available; NSAIDs, nonsteroidal anti-inflammatory drugs; OARSI, Osteoarthritis Research Society International; SOR, strength of recommendation; TENS, transcutaneous electrical nerve stimulation
* SOR (strength of recommendation) is an overall rating that reflects the opinions of OARSI team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. SOR is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.
^†Level of consensus is the estimated extent of agreement among committee members, expressed as a percentage.
^‡Level of evidence is broken into 6 categories: Ia: meta-analysis of randomized controlled trials (RCTs); Ib: RCT; IIa: controlled study without randomization; IIb: quasi-experimental study; III: nonexperimental, descriptive studies; and IV: expert committee reports/opinion/experience.
^§ES (effect size for pain relief) is a measure of the standard mean difference between interventions (eg, treatment vs placebo): 0.2 (small); 0.5 (moderate); and >0.8 (large). The ES refers to the knee and hip unless otherwise specified.
Adapted from: Zhang et al.⁴