Contemporary guidelines for the management of osteoarthritis (OA) from different stakeholder organizations are generally consistent, according to a systematic review of the literature undertaken as an initiative of the Chronic Osteoarthritis Management Initiative Work Group (Nelson AE, et al. Semin Arthritis Rheum. 2013 Dec 4. Epub ahead of print).
But despite the existence of consistent guidelines across a number of medical societies and organizations, uptake and implementation of OA guidelines is suboptimal in the United States, Canada, and European countries, ranging from 22% to 57%.
“Many of these recommendations from stakeholder organizations are generally agreed upon and could be readily implemented in clinical practice for a variety of specialties providing care to OA patients,” lead author Amanda E. Nelson, MD, MSCR, University of North Carolina, Chapel Hill, told Value-Based Care in Rheumatology. “The vast majority of care for OA occurs in primary care settings and efforts aimed at dissemination and implementation of these guidelines should be directed toward these providers for maximum impact.”
Dissemination and implementation of guidelines is an important area that is now receiving much attention, according to the investigators. “No matter how important and clinically relevant research-based findings may be, it is only through dissemination and implementation that such guidelines and/or research will reach the clinicians and patients who may benefit,” she added. Implementation of evidence-based guidelines will be tied to reimbursement, and may be used to create quality indicators and assess patient satisfaction.
The present study was based on a MEDLINE literature search of articles published on OA guidelines from January 1, 2000, to April 1, 2013. Of 148 articles, 16 were eligible for inclusion and included in the final analysis. The articles comprised recommendations from the American College of Rheumatology, European League Against Rheumatism, American Association of Orthopedic Surgeons, Osteoarthritis Research Society International, as well as other societies.
Fifteen of the 16 articles included recommendations that were in general agreement for nonpharmacologic management of OA: education and self-management; exercise and weight loss; assistive devices; alternative and complementary approaches; and surgical interventions. Education guidelines included patient referral to self-management, provide education, joint protection strategies and individualized plans for patients with OA. Exercise—including low-impact aerobic exercise and consideration of range-of-motion exercises—and weight loss were recommended. Assistive devices such as walking aids were recommended as needed, but there was inconclusive evidence to support bracing or lateral heel wedges for knee OA and for splints for thumb-based OA.
Six guidelines included surgical interventions. Guidelines that did recommend joint replacement for appropriate patients with hip or knee OA, stated that arthroscopy with debridement was not recommended for the management of symptomatic knee OA.
Regarding pharmacologic management, the guidelines recommended acetaminophen/paracetamol as first-line therapy for symptomatic OA, and second-line treatment with topical agents and oral nonsteroidal anti-inflammatory drugs, with appropriate risk stratification and gastroprotective strategies. Tramadol (Ultram) was recommended for refractory symptoms, and possibly opioids or duloxetine. Intra-articular corticosteroids were recommended for knee and hip OA, but there was insufficient evidence to make a general recommendation regarding intra-articular hyaluronans.
Guidelines were conflicting regarding acupuncture, glucosamine/chondroitin, and intra-articular hyaluronans. “Dissemination and implementation efforts should focus not on controversial recommendations, but on those with universal agreement, such as those for education, exercise, and weight loss,” Dr Nelson and colleagues concluded.