February 27, 2008 — The Osteoarthritis Research Society International (OARSI) has issued 25 evidence-based, expert consensus recommendations for the management of osteoarthritis (OA) of the hip and knee. These guidelines, which are published in the February issue of Osteoarthritis and Cartilage, were intended to be adapted for use in different countries or regions according to the availability of treatment modalities and strength of recommendation (SOR) for each modality of therapy.

"Osteoarthritis (OA) is the most common type of arthritis and the major cause of chronic musculoskeletal pain and mobility disability in elderly populations worldwide," write W. Zhang, PhD, from the University of Edinburgh, Osteoarticular Research Group, Queen's Medical Research Institute, Edinburgh, United Kingdom. "Knee and hip pain are the major causes of difficulty in walking and climbing stairs in the elderly in Europe and the USA and as many as 40% of people over the age of 65 in the community in the United Kingdom suffer symptoms associated with knee or hip OA."

The objective of these guidelines was to develop concise, current, patient-centered, evidence-based, expert consensus recommendations for the management of hip and knee OA. The panel intended these guidelines to be adaptable and designed them as an aid to clinicians and allied healthcare professionals in general and specialist practice throughout the world.

Goals of treatment of knee and hip OA include decreasing joint pain and stiffness, stabilizing and increasing joint mobility, reducing physical limitations and disability, improving health-related quality of life, limiting the progression of joint damage, and providing patient education regarding the nature and management of OA.

The medical literature has described more than 50 modalities of nonpharmacologic, pharmacologic, and surgical therapy for knee and hip OA. Despite the development of several National and Regional Guidelines to guide clinicians, allied healthcare professionals, and patients in their choice of treatment to manage knee and hip OA, there have been no internationally agreed-on and universally applicable guidelines for management.

In September 2005, OARSI convened a meeting of an international, multidisciplinary committee of experts to critically review all existing evidence-based and consensus guidelines as well as the recent research evidence and to develop up-to-date, evidence-based, globally relevant consensus recommendations for management of knee and hip OA in 2007.

The guidelines development team consisted of 16 experts in primary care, rheumatology, orthopaedics, and evidence-based medicine from the United States, the United Kingdom, France, the Netherlands, Sweden, and Canada. Using the validated appraisal of guidelines research and evaluation instrument, the team reviewed 23 existing guidelines published between 1945 and January 2006 and generated a core set of management modalities based on the agreement between guidelines.

Evidence before 2002 was based on a systematic review by the European League Against Rheumatism, and subsequent evidence was updated with use of MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library, and health technology assessment reports. Whenever feasible, effect size (ES), number needed to treat, relative risk or odds ratio, and cost per quality-adjusted life years gained were estimated. A Delphi exercise was used to produce consensus recommendations, and a visual analog scale was used to determine the SOR for propositions relating to each modality.

Of 51 treatment modalities addressed by the identified guidelines, 20 were universally recommended. Although ES for pain relief varied among treatments, overall there was no statistically significant difference between nonpharmacologic (0.25; 95% confidence interval [CI], 0.16 - 0.34) and pharmacologic (ES, 0.39; 95% CI, 0.31 - 0.47) modalities.

The team reached a consensus on 25 carefully worded recommendations and provided SORs and 95% CIs for each. Their overall conclusion was that optimal management of patients with hip or knee OA requires a combination of nonpharmacologic and pharmacologic treatment modalities.

Twelve recommendations describe the use of nonpharmacologic treatment modalities: education and self-management; regular telephone contact with healthcare providers; physical therapy referral with provision of canes or walkers when appropriate; aerobic, muscle-strengthening, and water-based exercises; weight loss in overweight patients; assistive devices including walking aids, knee braces, footwear, and insoles; thermal modalities; transcutaneous electrical nerve stimulation for short-term pain control; and acupuncture, which may help relieve symptoms in some patients.

Eight of the recommendations discuss pharmacotherapeutic agents including acetaminophen (up to 4 g/day); cyclooxygenase-2 (COX-2) nonselective and selective oral nonsteroidal anti-inflammatory drugs (NSAIDs) used at the lowest effective dose, with avoidance of long-term use; topical preparations of NSAIDs and capsaicin; intra-articular injections of corticosteroids and hyaluronates; symptomatic relief with glucosamine and chondroitin sulphate supplementation; possible structure-modifying effects associated with glucosamine sulphate, chondroitin sulphate, and diacerein; and indications for use of weak opioids and narcotic analgesics to treat refractory pain.

Five recommendations focus on surgical modalities, including total joint replacements, unicompartmental knee replacement, osteotomy and joint-preserving surgical procedures, joint lavage and arthroscopic debridement for knee OA, and joint fusion used as a salvage procedure when joint replacement has failed.

"Patients with hip or knee OA who are not obtaining adequate pain relief and functional improvement from a combination of non-pharmacological and pharmacological treatment should be considered for joint replacement surgery," the authors of the guidelines write. "Replacement arthroplasties are effective, and cost-effective interventions for patients with significant symptoms, and/or functional limitations associated with a reduced health-related quality of life, despite conservative therapy."

OARSI provided financial support for development of these guidelines. The authors of the guidelines have disclosed various financial relationships with such industrial entities as Abbott, AstraZeneca, Merck, Bristol-Meyers Squibb, GlaxoSmithKline, and Novartis. The complete list of disclosures is available in the original article.

Osteoarthr Cartil. 2008;16:137-162.

Clinical Context

Study Highlights

• The optimal management of OA of the hip and knee combines both nonpharmacologic and pharmacologic treatment modalities (SOR, 96%).
• The initial treatment of OA should focus on patient empowerment and self-driven therapies. All patients should receive education on lifestyle changes, exercise, pacing of activities, and weight reduction (SOR, 97%).
• Monthly telephone contact, even by lay personnel, can improve the clinical status of patients with OA (SOR, 66%).
• A physical therapy consultation focusing on appropriate exercises may benefit patients with OA, although this recommendation is largely based on expert opinion. The physical therapy visit may also include advice regarding assistive devices for ambulation (SOR, 89%).
• Weight loss is encouraged and can relieve pain and stiffness and improve function (SOR, 96%).
• Assistive devices for ambulation can reduce pain associated with OA. Frames or wheeled walkers are preferable for patients with bilateral disease (SOR, 90%).
• Among patients with knee OA and mild or moderate valgus or varus instability, a knee brace can reduce pain, improve stability, and reduce the risk of falling (SOR, 76%).
• Insoles can also reduce pain among patients with knee OA (SOR, 77%).
• Thermal modalities may improve knee OA, but there is less evidence that ice may be effective (SOR, 64%).
• Transcutaneous electrical nerve stimulation can help with short-term pain control among patients with hip or knee OA (SOR, 58%).
• Acupuncture can relieve symptoms of knee OA (SOR, 59%).
• Acetaminophen is the first choice for pharmacologic treatment of OA. Doses up to 4 g/day may be initiated before the use of other medications (SOR, 92%).
• NSAIDs may be used at their lowest effective dose, and long-term use should be avoided if possible. Among patients at an increased risk for gastrointestinal tract bleeding, clinicians should prescribe either a COX-2 selective agent or a nonselective NSAID with co-prescription of a proton pump inhibitor or misoprostol. NSAIDs should be used with caution among patients with cardiovascular risk factors (SOR, 93%).
• Topical NSAIDs and capsaicin can be effective as monotherapy or adjunctive treatment for OA of the knee (SOR, 85%).
• Patients with moderate to severe pain associated with knee OA that is not responding to oral therapy can be treated with intra-articular injections (SOR, 78%).
• Intra-articular injections of hyaluronate are associated with delayed onset of analgesia but a prolonged duration of action vs injections of corticosteroids (SOR, 64%).
• Treatment with glucosamine and chondroitin may relieve symptoms of OA, but treatment should be discontinued if there is no relief after 6 months of therapy (SOR, 63%).
• Unicompartmental knee replacement is effective among patients with knee OA restricted to a single compartment (SOR, 76%).
• Osteotomy may be considered for young adults with symptomatic hip OA, whereas high tibial osteotomy may reduce the need for joint replacement among young adults with knee OA (SOR, 75%).
• Joint fusion of the knee can be performed to salvage a failed joint replacement (SOR, 69%).

Pearls for Practice

• The current recommendations for nonpharmacologic treatment of OA of the hip and knee include regular telephone calls from the clinician's office; self-driven therapies; and education on lifestyle changes, exercise, and weight reduction. For patients with knee OA, a knee brace for varus or valgus instability, insoles for appropriate patients, acupuncture, and thermal therapy are recommended. However, the topical application of ice is less proved.
• The current guidelines for pharmacologic treatment of OA of the hip and knee recommend acetaminophen as the first choice. Other treatments include NSAIDs and glucosamine and chondroitin, but long-term use of these medications should be avoided.

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