Commentary on recent therapeutic guidelines for osteoarthritis

doi:10.1016/j.semarthrit.2014.12.003

Seminars in Arthritis and Rheumatism

Volume 44, Issue 6, June 2015, Pages 611-617

https://doi.org/10.1016/j.semarthrit.2014.12.003 Get rights and content

Abstract

Background

Despite availability of international evidence-based guidelines for osteoarthritis (OA) management, agreement on the different treatment modalities is lacking.

Method

A symposium of European and US OA experts was held within the framework of the Annual European Congress of Rheumatology to discuss and compare guidelines and recommendations for the treatment of knee OA and to reach a consensus for management, particularly for areas in which there is no clear consensus: non-pharmacological therapy; efficacy and safety of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs); intra-articular (i.a.) hyaluronates (HA); and the role of chondroitin sulfate (CS) and/or glucosamine sulfate (GS).

Results

All guidelines reviewed agree that knee OA is a progressive disease of the joint whose management requires non-pharmacological and pharmacological approaches. Discrepancies between guidelines are few and mostly reflect heterogeneity of expert panels involved, geographical differences in the availability of pharmacotherapies, and heterogeneity of the studies included. Panels chosen for guideline development should include experts with real clinical experience in drug use and patient management. Implementation of agreed guidelines can be thwarted by drug availability and reimbursement plans, resulting in optimal OA treatment being jeopardized, HA and symptomatic slow-acting drugs for osteoarthritis (SySADOAs) being clear examples of drugs whose availability and prescription can greatly vary geographically. In addition, primary care providers, often responsible for OA management (at least in early disease), may not adhere to clinical care guidelines, particularly for non-pharmacological OA treatment.

Conclusion

Harmonization of the recommendations for knee OA treatment is challenging but feasible, as shown by the step-by-step therapeutic algorithm developed by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). More easily disseminated and implemented guidance for OA treatment in the primary care setting is key to improved management of OA.

Introduction

Osteoarthritis (OA) has been defined as “a progressive disease of synovial joints that represents failed repair of joint damage that results from stresses that may be initiated by an abnormality in any of the synovial joint tissues, including articular cartilage, subchondral bone, ligaments, menisci (when present), peri-articular muscles, peripheral nerves, or synovium” [1]. Even if OA can involve single and/or multiple peripheral joints, including the knee, hip, and hand [2], the knee is the most common joint localization of symptomatic OA [3].

While diagnosis of OA is mainly based on clinical and radiological features [4], pain represents the first and prevailing symptom that leads patients to seek medical advice. Stiffness is generally linked to physical inactivity, while loss of movement and function can limit the patient’s daily activities. Symptomatic OA is often associated with depression and disturbed sleep, greatly reducing patients’ quality of life [2].

The current treatment of OA is based on symptom management, primarily pain control, and relies on the combination of non-pharmacological and pharmacological approaches that are generally tailored to the patient’s needs and risk factors. While several international professional societies have published evidence-based guidelines for OA management [5], [6], [7], [8], [9], [10], [11], no complete agreement on the different treatment modalities exists, highlighting the need for a debate to try to understand the differences and to develop a general consensus for disease management.

A symposium devoted to the recent therapeutic recommendations for OA management was held on June 12, 2014, in the framework of the 2014 Annual European Congress of Rheumatology to review, compare, and discuss the most important guidelines and recommendations for the treatment of knee OA published by the European League Against Rheumatism (EULAR), the Osteoarthritis Research Society International (OARSI), the American College of Rheumatology (ACR), and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).

This article summarizes the comparisons of the guidelines for knee OA treatment regarding four specific topics: the non-pharmacological therapy of knee OA, efficacy and safety of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular hyaluronates, and the role of chondroitin sulfate (CS) and/or glucosamine sulfate (GS) in the management of knee OA for which no clear cut consensus is available.

Section snippets

The non-pharmacological therapy of knee osteoarthritis

Table 1 presents the recommendations for non-pharmacological treatments issued over the past 10 years. The different recommendations rely on evidence from both systematic reviews and randomized clinical trials (RCTs), with the main outcomes considered being pain and physical function. While in patients with knee OA the most agreed non-pharmacological modalities are patient access to information and education, weight loss, and exercise programs, debate continues regarding the limited effects of

Analgesics and non-steroidal anti-inflammatory drugs (NSAIDs)

Pharmacological treatment aims to reduce pain, which is one of the earliest symptoms of the disease. Traditionally, pain relief has mainly relied on the use of analgesics and NSAIDs. Table 2 summarizes the recommendations for the use of this class of compounds in the management of knee OA. There is general agreement that paracetamol should be used as the initial analgesic for the management of symptomatic OA at the recommended daily dose of no greater than 3 g/day, given, for example, as a

Hyaluronates

Hyaluronic acid (HA) is a natural biological substance, a high-molecular-weight glycosaminoglycan. It is a major component of ligament, tendon, and cartilage structure and of synovial fluid, maintaining the visco-elastic properties of the latter. Since depolymerization of HA in the synovial fluid has been reported in OA, the mechanism of intra-articular (i.a.) HA administration is visco-supplementation. Preclinical and clinical evidence support the hypothesis that this treatment modality can be

Role of chondroitin sulfate (CS) or glucosamine sulfate (GS) in the management of OA

CS and GS are natural compounds, consisting of glycosaminoglycans (CS) or a glycosaminoglycan unit component (GS), that belong to the pharmacological class known as symptomatic slow-acting drugs for osteoarthritis (SySADOAs). They have demonstrated symptomatic effects and potential disease-modifying effects based on the measurement of radiological joint space narrowing (JSN) in some studies [39], [40], [41], [42], [43]. Despite the large quantity of published evidence, the efficacy of this

Discussion and concluding remarks

All of the guidelines reviewed during the debate agree that knee OA is a progressive disease of the joint whose management requires both non-pharmacological and pharmacological approaches. A close review of the different recommendations suggests that there are discrepancies between the guidelines. However, these are few and mostly reflect the heterogeneity of the expert panels involved in their production, differences in the availability of pharmaceutical-quality prescription drugs between

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Citation Excerpt :
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Systematic review and meta-analysis of randomized controlled trials (RCTs).
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: IBSA provided funding for medical writing assistance to HPS.

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Commentary on recent therapeutic guidelines for osteoarthritis

Abstract

Background

Method

Results

Conclusion

Introduction

Section snippets

The non-pharmacological therapy of knee osteoarthritis

Analgesics and non-steroidal anti-inflammatory drugs (NSAIDs)

Hyaluronates

Role of chondroitin sulfate (CS) or glucosamine sulfate (GS) in the management of OA

Discussion and concluding remarks

Osteoarthritis Cartilage

Lancet

Osteoarthritis Cartilage

Semin Arthritis Rheum

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Joint Bone Spine

Eur J Pain

Osteoarthritis Cartilage

Semin Arthritis Rheum

Maturitas

Lancet

Osteoarthritis Cartilage

Criteria for classification of clinical osteoarthritis

J Rheumatol Suppl

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

Ann Rheum Dis

American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee

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EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

Ann Rheum Dis

EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis

Ann Rheum Dis

Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis

Ann Rheum Dis

Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials

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Variations among primary care physicians in exercise advice, imaging, and analgesics for musculoskeletal pain: results from a factorial experiment

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Rheumatology in general practice

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Improving undergraduate musculoskeletal education: a continuing challenge

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