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PANLAR updates recommendations for osteoarthritis management
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The PANLAR consensus has updated its recommendations for osteoarthritis management of the hand, hip and knee.
A group of 48 specialists and three patients developed the recommendations by performing a systematic review of articles published between 2008 and 2014. They used the American Heart Association Evidence-Based Scoring System to determine the level of evidence and grade of recommendation. If there was evidence the treatment was effective, the researchers marked the recommendation as level 1.
Level 1 recommendations for management of hand osteoarthritis (OA) included the following:
- educate about joint protection, muscle strengthening and range of motion exercises;
- for patients with mild to moderate pain with few affected joints and in elderly patients with mild to moderate persistent pain, use topical nonsteroidal anti-inflammatory drugs (NSAIDs);
- for long-term treatment, use acetaminophen/paracetamol for up to 3 g per day, especially in elderly patients;
- for patients who present inadequate response to acetaminophen/paracetamol, use oral NSAIDs at the lowest effective dose for the shortest time possible, while considering the high risk for gastrointestinal and cardiovascular events;
- for pain relief and function, chondroitin sulfate can be used; and
- for treatment of hand and knee OA, glucosamine and chondroitin sulfate can be used.
Level 1 recommendations for hip OA included the following:
- educate about therapeutic objectives and the importance of exercise, weight loss, walking aids and shoe adjustments;
- strengthen the extensors and abductors to improve functionality or to prepare before a hip implant;
- thermotherapy can be performed to relieve pain;
- have the patient perform aerobic exercise on a regular basis;
- have the patient perform muscle stretching and strengthening and joint mobility exercises;
- for mild to moderate pain, use acetaminophen/paracetamol;
- for more severe pain, ibuprofen, naproxen, diclofenac, meloxicam, celecoxib or etoricoxib can be used at higher than normal doses;
- for patients with cardiovascular risks, naproxen can be used in conjunction with a proton-pump inhibitor; and
- for patients with pain walking difficulty and impaired quality of life, total hip arthroplasty can be performed.
Level 1 recommendations for knee OA included the following:
- educate about treatment goals and the importance of lifestyle changes;
- before patients perform flexion exercises, have them use heat to reduce pain and stiffness;
- for symptomatic OA, have the patient perform a program of flexibility, stretching and strengthening exercises;
- have the patient perform a daily walk;
- implement aerobic exercise gradually and progressively according to patient’s level of fitness for at least three times a week for 20 minutes per session;
- have the patient perform exercises for concentric contraction of the flexor and extensor muscles of the knee;
- for mild pain, use acetaminophen/paracetamol for up to 3 g per day and patients should be monitored for possible hepatic complications;
- for moderate pain, use diclofenac, ibuprofen, naproxen, celecoxib and etoricoxib along with a proton pump inhibitor. In addition, use naproxen for patients with cardiovascular risk;
- for moderate to severe pain, a combination therapy of glucosamine and chondroitin sulfate can be used;
- for severe pain, use tramadol;
- for patients with gastrointestinal risk, topical NSAIDs can be used;
- for any knee OA case, chondroitin sulfate can be used for up to 3 months; and
- for pain relief and improving joint function, glucosamine can be used.
“The pharmacological management of OA has traditionally been centered on analgesics and NSAIDs; however, increasing toxicity warning have been issued recently for paracetamol, traditional NSAIDs and COX-2 inhibitors, making OA chronic treatment even more challenging,” the researchers wrote. “The value and therapeutic efficacy of these agents are unquestionable, but there is growing awareness that they should be used for short time periods and for specific flares of the disease. The use of safer alternatives for long-term administration, such as chondroitin and glucosamine, is advisable and presents growing evidence of efficacy and safety, making them a suitable alternative for long-term control of the disease.” – by Will Offit
Reference: The researchers report no relevant financial disclosures.
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