For the first time, OARSI has developed guidelines for the non-surgical treatment of osteoarthritis of the knee that are stratified to each of four patient groups: patients with knee-only OA and no comorbidities, patients with knee-only OA with comorbidities, patients with multi-joint OA and no comorbidities, and patients with multi-joint OA with comorbidities. Comorbities included diabetes, hypertension, cardiovascular disease, renal failure, GI bleeding, depression, or a physical impairment limiting activity, including obesity.
After a comprehensive review of the current scientific evidence, each working group member gave each treatment a score for appropriateness, therapeutic benefit, and overall risk for each of the four different patient populations. These scores were converted into a recommendation category of either “appropriate”, “not appropriate”, or “uncertain” and a composite risk-benefit score.
It is important to note that an “uncertain” recommendation is NOT a negative recommendation, nor is it meant to rule out the use of a therapy. Instead, this category means that the working group found too little scientific evidence to support a recommendation or that a treatment has a moderately high risk profile coupled with low efficacy. As such, “uncertain” treatments should be weighed by physicians and patients for merit in specific, individual circumstances.
The new guidelines recommend a set of non-pharmacological core treatments as appropriate for all individuals (listed in order from highest benefit-to-risk score to lowest): land-based exercise, weight management, strength training, water-based exercise, and self-management and education. For weight management, the OARSI guidelines make a specific recommendation of achieving a 5% weight loss within a 20-week period to be effective at treating knee OA.
Key Updates to the 2010 OARSI Guidelines:
- Topical NSAIDs are recommended as appropriate for all patients with knee-only OA and in a scientific review, were found overall to be safer and better tolerated compared to oral NSAIDs.
- The prescription drug duloxetine was evaluated for the first time and found to be an appropriate treatment for knee-only OA patients without comorbidities and all multi-joint OA patients.
- Due to increased safety concerns about toxicity, acetaminophen/paracetamol was given an “uncertain” recommendation for all patients with comorbidities.
- Oral and transdermal opioid painkillers were given an “uncertain” recommendation for all patient groups due to concerns about increased risks for adverse and serious adverse events.
- Glucosamine and chondroitin were both found to be “not appropriate” for all patients when used for disease modification and “uncertain” for all patients when used for symptom relief.
- Balneotherapy, defined as using baths containing thermal mineral waters, was evaluated for the first time and found to be an appropriate therapy for patients with multi-joint OA and comorbidities, as this group has few other treatment options.