Medical Management of Knee Osteoarthritis (Phil CPG 2009)

Based on the 2003 National Nutrition and Health Survey (NNHeS), 0.5% of the population have osteoarthritis (OA) – making it the second most prevalent arthritic condition (next to gout). The knee is the most commonly involved joint in 80% of Filipino patients. Although more patients are females in their 5th decade of life, male OA patients actually experience more severe pain, greater disability and poorer health status.

 A lot of therapies and interventions claim to be effective in treating osteoarthritis (some even going as far as branding themselves as “cures”). However, not all of them are backed by the evidence. Clinical practice guidelines are important in promoting interventions that are proven to work and discouraging the use of those that may be harmful or ineffective.

 Our colleagues from the Philippine Rheumatology Association came up with evidence-based recommendations for the medical management of knee OA that is differentiated from other guidelines by its review of complementary and alternative medicines (CAMs). Below are excerpts of these recommendations (with their level of evidence [LOE] indicated in parentheses).

Patient education – consisting of physician advise and reading materials – is recommended in the control of pain in knee OA. (LOE: Low) There is insufficient evidence to recommend structured arthritis self-management programs over the usual clinical practice. (LOE: High)

  1. Weight loss of at least 5% is recommended in improving pain and function of patients with knee OA. This is particularly important among overweight and obese patients. (LOE: High)

  2. Paracetamol is recommended for reducing pain among patients with mild knee OA. Although doses of 4 grams/day may be used, closer monitoring of GI adverse events is recommended when using doses >2 grams/day. (LOE: High)

  3. Tramadol is recommended to improve pain and function among patients with moderate knee OA. Patients should be properly advised regarding adverse events like dizziness and vomiting. (LOE: High)

  4. Oral NSAIDs and/or COXIBs for 2 weeks may be used in treating exacerbations of knee OA in patients without GI, cardiac and renal risk factors for adverse events. (LOE: High)

  5. In patients whom oral/ systemic therapy may be contraindicated, topical NSAIDs may be used in treating OA exacerbations. (LOE: High)

  6. Intra-articular steroids, administered by experts, are an effective and safe option for treating OA exacerbation with duration of effect of 1-3 weeks. (LOE: High) IA steroids should not be given >3 / year to the same joint. (LOE: Low) There is no data on the use of oral steroids in OA.

  7. Intra-articular hyaluronic acid, administered by experts, are effective for treating patients with moderate OA. It has a longer duration of effect (5-13 weeks) compared to IA steroids. (LOE: Moderate) IA Hyaluronic Acid may also be considered as bridge therapy for patients awaiting surgical management. (LOE: Low)

  8. Pharmaceutical grade glucosamine sulfate can be used for its modest effect on pain and function among patients with knee OA. (LOE: High) Data for pharmaceutical grade preparations cannot be extrapolated for nutraceutical and other non-bioequivalent formulations (LOE: Low)

  9. Glucosamine hydrochloride, Chondroitin sulfate or their combination is not recommended for knee OA. (LOE: Low for Glucosamine HCl, High for Chondroitin and Moderate for Combination preparation)

  10. Manual or electro-acupuncture may be used as additional therapy for patients with moderate OA. The procedure must be performed by a trained and experienced acupuncturist. (LOE: High) There is insufficient evidence to support the use of spa/ balneotherapy, tai ch’i, yoga and (standard Swedish) massage. (LOE: Low)

  11. Concentrated standardized ginger preparation has moderate effects on pain and function in knee OA. Patients should be warned of potential GI adverse events when using this preparation. (LOE: Moderate) There is insufficient data on comfrey, Chinese herbal recipe, Chinese pills, rose hip, devil’s claw, to recommend their use in knee OA.

However, the above guidelines did not discuss exercise/ rehabilitation as part of the cornerstones of OA management – specifically improving quadriceps strength which has been shown in epidemiologic studies to be protective for knee OA. One trial – the Fitness Arthritis and Seniors Trial (FAST) – enrolled patients with mild disability from knee OA and were given the following interventions: resistive (muscle strengthening) exercise, aerobic exercise or education/ attention (serving as control). Patients who were were randomized to both exercise groups had modest improvements in pain and function which were sustained over an 18 month follow-up period. And it was also found in the post-hoc analysis that those who were more adherent to the exercise program had greater improvements in pain and function.

Another area not addressed by the recommendations is the duration of pharmacologic treatment. With the exception of oral NSAIDs and COXIB use, prescribing medications on an “as needed” versus “round the clock” regimen is a common question many physicians ask.

 References:

  1. Abao-Lim J, Fabia S, Tanopo L, et al. Profile of the Filipino Osteoarthritis Patient. Paper Presentation. PRA 1994.
  2. Penserga EG, Salido EO, del Rosario AG, et al. PRA Clinical Practice Guidelines for the Medical Management of Knee OA. Unpublished 2009.
  3. Ettinger WH Jr, Bums R, Messier SP, Applegate W, Rejeski WJ, Morgan T, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: the Fitness Arthritis and Seniors Trial (FAST). JAMA 1997;277:25-31.
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