Knee OA guidance for clinicians simplified and streamlined

The burden of knee osteoarthritis is set to continue to increase around the world. Aging populations and rising levels of obesity, combined with an absence of a cure for the disease, will lead to an increased strain on health-care systems. Due to this, there is a focus on how to best manage the disease.

Clinical management is difficult and recommended treatment strategies routinely include a combination of non-pharmacological, pharmacological and in some cases surgical interventions. Management can further be categorized by disease severity, joint site and the presence/absence of comorbidities making OA treatment increasingly personalized.

Facing such complexities, health-care providers turn to clinical practice guidelines to help inform the decision-making process. But according to a research team from the Universities of Oxford, Southampton, Liège, Oulu, Maryland, Oslo and Boston, the complexities for clinicians don't end there.

"Leading experts and national and international organizations frequently publish guidelines outlining the best strategies for managing osteoarthritis," said Thomas Perry, joint first author and Postdoctoral Research Fellow in Sport, Exercise and Osteoarthritis at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford. "There are a number of OA organizations across the world, each publishing new updated algorithms for how to best manage osteoarthritis, which means it can be difficult for clinicians to keep track of the most up-to-date literature, best practice policies, and ultimately provide the best care for their patients."

In 2019, when OARSI (Osteoarthritis Research Society International) and ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis) updated their guidelines for the non-surgical management of knee osteoarthritis, Nigel Arden, Professor of Rheumatic Diseases at NDORMS proposed a review of their new algorithms. Together with members from OARSI and ESCEO, a working group examined the similarities and differences between the two guidelines and created a narrative to help guide health-care providers through the complexities of treatments.

The results are published today in Nature Reviews Rheumatology.

The guidelines are similar in the majority of their recommendations. OARSI and ESCEO both recommend education, structured exercise and weight loss as core treatments for knee OA and advise the use of topical NSAIDs as first-line treatments, and oral NSAIDs and intra-articular injections for persistent pain. Where they differed was in ESCEO's recommendation for the use of low-dose, short-term acetaminophen, pharmaceutical grade glucosamine and chondroitin sulfate, as compared to OARSI which strongly recommends against their use (including all glucosamine and chondroitin formulations). Thomas said: "It's reassuring that the majority of recommendations from OARSI and ESCEO are in agreement. The working group concluded that the most likely reason for the differences were down to the methodologies of how they each approach the data and the literature. Each organization uses slightly different procedures which could translate into the few, but important differences observed. It also highlights that there remain contested treatments for which we need better quality data to confirm use or non-use in the management of knee OA. Moving forward, there is also a need to define a standard protocol, outlining a method for making treatment algorithms which can be adopted by all societies."

Professor Arden said: "It was the first time that OARSI and ESCEO had come together to discuss their guidelines and it proved a very positive experience. Our aspiration would be to expand the collaboration to other societies and to harmonize the algorithms in order to present a consistent set of recommendations, providing confidence and clarity for practicing clinicians regarding the treatment for their patients."