Osteoarthritis: Which treatments work and which don’t?

A newly released set of treatment recommendations for knee and hip osteoarthritis may help millions of people worldwide who live in pain due to inconsistent treatment approaches and confusion about what therapies are most effective.

The 25 evidence-based, expert-consensus recommendations appear in the February issue of Osteoarthritis and Cartilage.

These are the first evidence-based recommendations developed by a committee that was brought together two years ago by the Osteoarthritis Research Society International (OARSI). The goals were (1) to review all of the published national and regional treatment guidelines together with the more recent evidence from clinical trials and (2) to produce a single set of up-to-date, evidence-based recommendations for the worldwide treatment of knee and hip osteoarthritis.

"What the committee did was take the scientifically proven commonalities it found in the international literature, evaluate the level of scientific evidence, propose a strength of recommendation for each modality, and condense them into one comprehensive ‘playbook’ of what works," says OARSI President Dr. Steve Abramson, director of Rheumatology and professor of Medicine at New York University School of Medicine.

The first of OARSI’s 25 evidence-based recommendations is that optimal treatment requires both nonpharmacologic and pharmacologic modalities. The remaining 24 recommendations fall into three categories — nonpharmacologic, pharmacologic and surgical.

The effectiveness of each recommendation is associated with a level of scientific evidence available to support it. The higher the level of support (expressed as a percentage out of 100), the more evidence in the scientific literature that the treatment is effective. The following are the recommendations:

• Nonpharmacologic – These 11 recommendations include education and self-management (97%); regular telephone contact (66%); referral to a physical therapist (89%); aerobic, muscle strengthening and water-based exercises (96%); weight reduction (96%); walking aids (90%); knee braces (76%); footwear and insoles (77%); thermal modalities (64%); transcutaneous electrical stimulation (58%); and acupuncture (59%).
• Pharmacologic — These eight recommendations include acetaminophen (92%); non-selective and selective oral nonsteroidal anti-inflammatory drugs (NSAIDs) (93%); topical NSAIDs and capsaicin (85%); intraarticular injections of corticosteroids (78%); intraarticular injections of hyaluronans (64%); glucosamine and/or chondroitin sulphate for symptom relief (63%); glucosamine sulphate, chondroitin sulphate and/or diacerein for possible structure-modifying effects (41%); and the use of weak opioids and narcotic analgesics for the treatment of refractory pain (82%).
• Surgical — These five recommendations include total joint replacement (96%); unicompartmental knee replacement (76%); osteotomy and joint preserving surgical procedures (75%); joint lavage and arthroscopic debridement in knee OA (60%); and joint fusion as a salvage procedure when joint replacement had failed (69%).

"Our goal was to make these guidelines as simple as possible so that healthcare providers could determine which therapies would be most useful for an individual patient," says Dr. Francis Berenbaum, president elect of OARSI and a faculty member in the Department of Rheumatology at Pierre & Marie Curie University, APHP Saint-Antoine Hospital in Paris.

Nearly all of the previous guidelines were created before the recent discussion about the potential cardiovascular risks of nonsteroidal anti-inflammatory drugs (NSAIDs) took place. In recent years, there has been a decline in the use of NSAIDs to reduce pain and inflammation caused by osteoarthritis, primarily due to their potential for causing gastrointestinal side effects and the perceived cardiovascular risks associated with these drugs.

However, members of the OARSI committee found that NSAIDs are often effective pain relievers and their short-term use should be considered on a case-by-case basis and not as a long-term option.

"As a consequence of the confusion over NSAIDs, some people may not be getting the care they need for pain," says Abramson.

The OARSI recommendations make up the first truly international guidelines for the treatment of knee and hip osteoarthritis. The guideline committee was made up of experts from six countries, including 11 rheumatologists, two primary care physicians, one orthopaedic surgeon, and two experts on evidence-based medicine.

Osteoarthritis is the most common type of arthritis and the major cause of chronic musculoskeletal pain and mobility limitation in elderly populations worldwide.

(Source: Osteoarthritis and Cartilage: Osteoarthritis Research Society International: February 2008)