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Updated knee, hip, polyarticular OA treatment guidelines target complicated patients
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TORONTO — The updated OARSI knee, hip, and polyarticular OA recommendations were developed to account for the various comorbidities that can arise in these patients, according to presenter Raveendhara R. Bannuru, MD, director of the Center for Treatment Comparison and Integrative Analysis at Tufts University School of Medicine.
“The major goal was to try to make guidelines more patient-centric,” Bannuru told attendees at the OARSI 2019 World Congress on Osteoarthritis, noting that the guideline development team voted on individual recommendations based on a 15-point matrix comprised of the three disease states and five comorbidity groups. “We made it more personalized by defining five comorbidity groups,” Bannuru said.
Bannuru offered some important definitions used by the group. “Core treatment was defined as a treatment recommendation for use in the majority of patients at any point in the course of treatment as appropriate,” he said. “There was a high-level summary of evidence for each of these interventions.”
The challenge, however, was that there was often not enough evidence available to offer a strong recommendation for the full knee, hip, or polyarticular OA patient population, or for any given disease state/comorbidity population.
Guideline highlights
In terms of overall highlights, mind-body exercise was recommended as a core treatment for knee OA, but tai chi and yoga are the only currently recommended approaches, according to Bannuru. Topical NSAIDS are strongly recommended for knee OA. “Certain oral NSAIDS are not recommended for certain comorbidity classes,” Bannuru said. Aceteminophen and opioids are not recommended.
“Weight management is recommended for patients with BMI over 30,” Bannuru said.
“For NSAID risk mitigation, we recommend the lowest possible dose for the shortest duration of time in patients with comorbidities.”
Looking more closely at the specific sub-populations, core treatments for knee OA included arthritis education as a standard of care. Structured land-based exercise to improve strengthening and balance received level 1b or 2 status. Weight management received a lower designation of recommendation.
For hip or polyarticular OA, the strongest recommendations were also for arthritis-based education and structured land-based exercise.
The picture becomes more complicated when comorbidities are factored into the equation. For example, for patients with knee OA and no comorbidities, oral NSAIDS were recommended as level 1b. However, for those with knee OA and gastrointestinal comorbidities, oral NSAIDS move down from a level 1b recommendation to level 2. For patients with knee OA and widespread pain or depression, there is no level 1a recommendation; NSAIDs and proton pump inhibitors (PPI) are level 1b recommendations for this patient population.
Similarly, there is no strong level 1a recommendation for patients with hip OA and no comorbidities. The level 1b recommendation for this patient population includes non-selective NSAIDs. There are no level 1a recommendations for patients with hip OA plus cardiovascular comorbidities.
For patients with polyarticular OA and no comorbidities, there are no level 1a recommendations. The level 1b recommendation for this group is NSAIDs.
Bannuru discussed what the patients hoped to see from this guideline. “Patient representatives wanted a complete list of strongly recommended or not recommended treatments, and the rationale for them,” he said.
Developing the document
The guideline team consisted of a core expert panel, a literature review team, and a voting panel. The group was multinational, with the expert panel consisting of individuals from four countries and the voting panel comprised of individuals from 10 countries. Surgeons, physical therapists, rheumatologists, and general practitioners participated. Bannuru highlighted that patients also participated in the development of the document. “Transparency was the major factor here,” he said.
The flow of evidence began with 12,500 abstracts, which were culled down to 1,200 full text studies. “Evidence was taken from 407 articles,” Bannuru said. —by Rob Volansky
Reference:
McAlindon TE. OARSI Treatment Guidelines Update. Presented at: OARSI 2019 World Congress on Osteoarthritis; May 2-5; Toronto, Canada.
Disclosure: Bannuru reports that the guidelines received no industry funding.