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Algorithm proposes when PCPs should treat osteoarthritis
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The International Rheumatologic Board — consisting of eight experts from six different countries — recently developed an algorithm to help primary care physicians determine whether they should treat osteoarthritis or if they should refer such patients to a specialist.
“The need to establish guidelines for the diagnosis of [osteoarthritis] in primary care arose from recognizing that diagnostic uncertainties exist in this setting and that [general practitioners] have limited time to devote to a chronic disease with few effective management solutions,” board member Johanne MartelPelletier, PhD, of the Osteoarthritis Research Unit, University of Montreal Hospital Research Centre, and colleagues wrote in Aging, Clinical and Experimental Research.
“In everyday practice, general practitioners may be unsure about when to refer patients, often for fear of ‘bothering’ specialists with a ‘simple’ case of osteoarthritis. Some patients are referred for unnecessary examinations, others at a late stage, and others who could receive primary care. Management delays represent a missed opportunity for the patient and can result in suboptimal outcomes,” they continued.
Hip
The board recommended PCPs use hip pain and osteophytes and/or radiographic joint space narrowing as preliminary diagnostic criteria for hip osteoarthritis.
Patients older than 70 years and those aged 50 to 70 years who neither have morphological anomalies on plain radiographs nor pain of “abnormal intensity or duration” should be treated by a PCP.
Conversely, those with morphological anomalies visible on plain radiographs, younger than 50 years with dysplasia or labrum, those aged 50 to 70 years with a subchondral bone microfracture or “rapidly destructive coxarthrosis” should be referred to an orthopedic specialist, the board wrote.
Knee
The board indicated MRI is not needed for a preliminary diagnosis of knee osteoarthritis. Instead, PCPs should use the person’s age (older than 50 years) and X-ray findings of joint space narrowing and/or osteophyte(s) in the last 6 months, or metabolic/inflammatory syndrome associated with the knee pain.
PCPs should refer patients with recurrent pain or those for whom NSAIDs do not work, those who present with pain that is intense, unusual and/or “abnormal” or those with knee effusion, to an expert, according to the board.
Hand/Finger
The board wrote family history of hand/finger pain and X-rays showing joint space narrowing should be the first diagnostic criteria for hand/finger pain.
PCPs should check for the presence of deformity and determine if the pain is base-of the-thumb or interphalangeal osteoarthritis due to these conditions’ different physio pathogenesis.
However, women younger than 50 years who are not menopausal, all patients whose hands and fingers are swollen, experiencing isolated metacarpophalangeal joint pain, psoriasis, or persistent pain in several joints should be referred to a specialist, according to the board.
“The feedback received after consultation with rheumatologists and general practitioners validated most aspects of these guidelines and informed several important amendments" to the final version, Martel-Pelletier and colleagues wrote.
“The next step should be to conduct a large impact study of implementation of these recommendations in the diagnostic management of osteoarthritis in general practice in different areas,” they concluded. – by Janel Miller
Disclosures : Martel-Pelletier reports being a shareholder of ArthroLab Inc, and receiving consultant fees from Bioiberica, Pierre Fabre, TRB Chemedica, and Zoetis. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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P. Maxwell Courtney, MD
As the U.S. population ages, osteoarthritis is rapidly becoming one of the most common conditions primary care physicians manage in the office. These clinicians know the patient the best and often act as the gateway to specialist care, referring when appropriate. Most PCPs are usually quite comfortable with the nonoperative treatment modalities of osteoarthritis such as anti-inflammatory medications, activity modification and physical therapy, and some will even provide corticosteroid injections.
I recognize that it is not always easy to get a panel of authors from all over the world to come to a consensus on a subject as broad as management of osteoarthritis. I commend Martel-Pelletier et al, for their efforts in assembling an international panel to develop a consensus for diagnosis and management of osteoarthritis by primary care physicians.
I do have some concerns, however, with following an algorithm that groups patients by age alone. For example, the authors note that anyone more than 70 years old with osteoarthritis of the hip should be managed exclusively by a primary care physician. A large percentage of total hip replacements I perform are on patients older than 70 years with very good outcomes. The authors also do not emphasize patient history and physical exam in their algorithm. I see many patients in the office reporting hip or knee pain and find that their symptoms are often from their lumbar spine. Likewise, a thorough history allows an insight into a patient’s functional status. Someone who can no longer tie his or her shoes or now needs a cane to walk two blocks due to debilitating osteoarthritis might benefit from an earlier referral to a subspecialist. This specialist does not always have to be an orthopedic surgeon.
PCPs should consider referral when nonoperative treatment modalities fail, there is a question in diagnosis of osteoarthritis based on history, exam, and radiographic findings, or if the patients’ functional status warrants. At the Rothman Institute and in other orthopedic practices, there are many talented non-operative fellowship-trained sports medicine experts who can help provide the appropriate treatment.
Rothman Orthopaedics
Philadelphia
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