Practical Tips in the Treatment Of Osteoarthritis of the Knee
Recently, the American College of Rheumatology (ACR) released revised recommendations for treatment of knee osteoarthritis.1 These recommendations incorporate the latest evidence-based options for treating knee arthritis. The newly revised recommendations add to the recommendations of four other organizations that have published arthritis treatment guidelines in the last 10 years—American Academy of Orthopaedic Surgeons (AAOS),2 European League Against Rheumatism (EULAR),3 Osteoarthritis Research Society International (OARSI),4 and the British National Institute for Health and Clinical Excellence (NICE).5 We will highlight the common recommendations using the ACR guidelines as the standard and discuss other treatment options that are available to practitioners.
Osteoarthritis is one of the most common causes of disability in adults. The prevalence increases with age, with a surprising 13.9% of the population over 25 years old being affected and 33.6% of the population over 65 years old affected.6
There are no specific pharmacologic treatments that prevent progression of the disease. Treatment is aimed at reducing pain and improving function. There are currently over 100 modalities described in the medical literature for treatment of osteoarthritis.
In this paper, we will use the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach for classifying current recommendations, which is the same approach used by ACR and many other organizations.1,7-9 Using this approach, interventions will receive one of four designations: strongly recommend, conditionally recommend, conditionally not recommend, and no evidence/evidence lacking.
The ACR divides their recommendations into pharmacologic and non-pharmacologic interventions. Separate recommendations are made for hip, knee, and hand osteoarthritis, but for the purpose of this article we will focus on knee osteoarthritis. The ACR did not make any recommendations on surgical interventions. The recommendations assume that the patient has already tried and failed intermittent over-the-counter (OTC) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and nutritional aides (glucosamine, chondroitin).1
The ACR did not “strongly recommend” any medications for the initial management of knee osteoarthritis. Acetaminophen, NSAIDs (oral and topical), tramadol, and intra-articular steroids are conditionally recommended for arthritis treatment depending on the clinical scenario (Table 1). For example, patients with a history of heart disease or peptic ulcer disease may need to be selective on the type of NSAID that is used, avoiding those with higher risks.1
The ACR considers non-pharmacologic measures to be the foundation for knee osteoarthritis treatment. Land-based or aquatic exercise and weight loss (for those who are overweight) are strongly recommended to be tailored to the individual’s abilities and comorbid conditions. Self-management programs to learn more about arthritis and how to manage the disease, manual therapy with supervised exercise, psychosocial interventions, and medially directed patellar taping are conditionally recommended. There is no recommendation made for balance exercises, laterally wedged insoles, manual therapy alone, and knee braces (Table 2).1
In patients who do not desire surgical treatment or have medical conditions that preclude surgery, the ACR guidelines recommend that patients who fail initial medication management and non-pharmacologic interventions strongly consider opioid treatment following the recommended guidelines.1,10 Duloxetine (Cymbalta), transcutaneous electrical nerve stimulation (TENS), and traditional Chinese acupuncture are conditionally recommended in patients who have failed initial interventions.1
Other Treatment Options
It is recommended to use multiple modalities in treating osteoarthritis of the knee as no single modality provides complete relief of symptoms.3 Combining multiple modalities allows for synergy among the different treatments and often provides better pain relief for patients. There are six types of interventions that should be considered for the treatment of knee osteoarthritis: oral medications, injectable medications, complementary and alternative remedies, lifestyle interventions, braces/devices, and surgical therapy (Figure 1). Most of these treatments have a small to moderate impact on osteoarthritis pain; therefore, using multiple modalities makes sense in improving patients’ osteoarthritis symptoms.
There is general consensus among all the guidelines that supports the use of acetaminophen, oral NSAIDs, topical NSAIDs, and tramadol.1-5 Reflecting recent warning from the FDA, the ACR cautions that if a patient is prescribed acetaminophen in the full dosage (up to 4,000 mg/d), the patient should be counseled to avoid all other products containing acetaminophen, including OTC cold remedies as well as combination products with opioid analgesics.1
Oral NSAIDs are associated with a dose-dependent risk of gastrointestinal, cardiovascular, hematologic, hepatic, and renal adverse events (AEs).11 The risk of gastrointestinal side effects can be lessened by using a cyclooxygenase (COX)-2 selective NSAID (Celebrex) or by combining non-selective NSAIDs with proton pump inhibitors.12 Concerns about cardiovascular events with COX-2 selective NSAIDs have limited the use of this class of medications in patients who have cardiovascular risk factors.13