OARSI provides guidance on non-surgical management of knee osteoarthritis

Osteoarthritis (OA) of the knee is a major cause of pain and disability affecting a growing number of patients due to population aging. Recently released evidence-based, expert consensus guidelines from the Osteoarthritis Research Society International (OARSI) provide recommendations on the use of available non-surgical therapies for patients with OA.

Although the OARSI issued guidelines on management for OA of the hip and knee in 2010, an update focusing only on OA of the knee was undertaken in recognition of the emergence of new data and differences in clinical considerations between the two conditions. Modalities evaluated for the first time in the updated guidelines include duloxetine and balneotherapy.

The recommendations are based on a systematic review of literature published through March, 2013, and stratification of patients into four phenotype subgroups defined by whether OA involves the knee only or additional joints plus the absence or presence of co-morbid health concerns, including diabetes, hypertension, cardiovascular disease, renal failure, gastrointestinal bleeding, depression, or physical impairment limiting activity, including obesity.

The expert panel developing the guidelines recommended a core group of non-pharmacological treatments as appropriate for all patients with knee OA. Listed in order of descending benefit-to-risk score these modalities included: land-based exercise; weight management; strength training; water-based exercise; and self-management and education.

Next: Biomechanical interventions and intra-articular corticosteroids

Biomechanical interventions and intra-articular corticosteroids were also recommended as appropriate for knee OA patients in all four subgroups, and oral selective nonsteroidal anti-inflammatory drugs (NSAIDs; including cyclo-oxygenase-2 inhibitors) were recommended treatment for all subgroups except patients with knee-only OA having co-morbidities. Topical NSAIDs and a walking cane were recommended for all patients with knee-only OA, regardless of co-morbidities.

The panel noted that according to available evidence, topical NSAIDs are associated with better safety and tolerability than oral NSAIDs. The recommendation of acetaminophen only for patients without co-morbidities was based on the potential toxicity of the analgesic.

The panel gave an uncertain recommendation to use of: oral and transdermal opioid painkillers based on safety concerns; glucosamine and chondroitin for symptom relief; and capsaicin in subgroups other than knee-only OA without co-morbidities. The uncertain recommendation does not mean these agents should not be used, but rather that there is insufficient scientific evidence to support their use or reflects low efficacy with moderately high risk. However, use of glucosamine and chondroitin for disease modification were considered “not appropriate.”

Multiple other non-surgical interventions were reviewed and rated. The complete report was published in the official journal of the OARSI [McAlindon TE, Bannuru RR, Sullivan MC, et al., OARSI guidelines for the non-surgical management of knee osteoarthritis, Ostearthritis Cartilage, 2014;22(3):363-88] and is available online at www.oarsi.org/education/oarsi-guidelines.