PRAGUE — The first international recommendations for the treatment of knee and hip osteoarthritis are expected to be announced within the next few months, according to the committee that drafted the guidelines.
“We hope these recommendations will target both primary care physicians and specialists, as well as allied health professionals,” said Dr. George Nuki, cochair of the guideline committee, and professor at the University of Edinburgh. “Publication is expected in two parts in Arthritis and Cartilage in the first quarter of 2007,” said Dr. Nuki at the 2006 World Congress on Osteoarthritis.
The guidelines were drafted by 16 experts drawn from rheumatology, primary care, orthopedics, and evidence-based medicine from six countries. These represent the first international guidelines on knee and hip osteoarthritis and are intended to be more broadly based than are the existing guidelines, said Dr. Roland Moskowitz, the other cochair of the committee and professor of medicine at Case Western Reserve University, Cleveland.
“We intend the guidelines to be universally applicable. We have evaluated treatments regardless of cost, and they can be universally applied according to different countries' health care systems,” Dr. Moskowitz said in an interview at the meeting, sponsored by the Osteoarthritis Research Society International.
The committee drafted a list of 34 recommendations, he said. There is 1 general recommendation suggesting that “optimal management of patients with OA of the hip and knee requires a combination of nonpharmacological and pharmacological modalities of treatment in most patients and surgery in some,” followed by 14 nonpharmacologic, 12 pharmacologic, and 7 surgical recommendations for treatment.
The draft of the proposed guidelines involved a systematic review of existing literature, said Dr. Nuki. The quality of evidence was evaluated and, when possible, outcome data for efficacy, adverse effects, and cost-effectiveness were abstracted. The effect size, number needed to treat, relative risks or odds ratio, and cost per quality of life years gained were estimated. Draft recommendations were produced following a Delphi exercise, based on a critical appraisal of the literature and the clinical expertise of the committee, he explained.
Nonpharmacologic therapies proposed included education of patients, changes in lifestyle, exercise, weight reduction, walking aids, patellar taping, modified footwear, knee braces, acupuncture, and transcutaneous electrical nerve stimulation.
Proposed pharmacologic treatments included acetaminophen (up to 4g/day) as the preferred first-line therapy. Alternative or additional analgesics to be considered for nonresponders included NSAIDs at the lowest effective dose, topical NSAIDs or capsaicin, and intra-articular injections of corticosteroids or hyaluronans.
The choice of treatments should be based on comorbidities, concomitant medication, and relative efficacy and safety, according to the proposed guidelines. In patients with increased GI risk, a cyclooxygenase-2 (COX-2) selective agent or a nonselective NSAID with a proton pump inhibitor or misoprostol for gastroprotection may be considered, but NSAIDs—including COX-2-selective agents—should be used with caution in patients with cardiovascular risk, the committee noted. Although chondroitin and glucosamine sulfate may provide some symptomatic benefits in patients who have knee OA, the use of opioid analgesics should be considered for the treatment of severe or refractory pain only when other agents are ineffective or contraindicated.
And finally, consideration of joint-replacement surgery was proposed for patients who do not receive adequate relief from pharmacologic and nonpharmacologic treatments, according to the draft recommendations.
After the finalized recommendations have been published, the organization hopes to encourage implementation of the guidelines in both primary- and secondary-care settings, said Dr. Nuki.
“We intend to revise them as new evidence emerges, with a full review planned in 2010,” he said. The guidelines are available at www.oarsi.org