Four-Step Plan for Managing Knee Osteoarthritis

Bruyère  O, Pelletier JP,  Branco J et al., An Algorithm Recommendation for the Management of Knee Osteoarthritis in Europe and Internationally: A Report From a Task Force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arth Rheum. (2014) Accepted Manuscript (e-pub ahead of print May 27)

An international task force of osteoarthritis (OA) experts is proposing a four-step plan to prioritize management strategies for symptomatic knee OA -- from supplements to surgery.

The 13-member task force, assembled by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO), also recommends weight loss (if needed) of least 10% of total body weight “to achieve significant symptom benefit.” A similar weight loss threshold “has also been indicated to improve the quality and thickness of medial femoral compartment cartilage,” the task force notes.

Education and a progressive, mixed program of exercise to build aerobic capacity, strengthen the quadriceps, and increase flexibility (including tai chi and water exercise) are recommended for all patients during all steps of the proposed treatment algorithm:  

Step 1, Background Therapy: Includes physical interventions (knee re-alignment, knee braces, orthotics, and canes), as-needed acetaminophen/paracetamol (no more than 3 g a day), topical therapy containing steroidal anti-inflammatory drug (NSAIDs), and prescription-strength glucosamine (1500 mg/day).

Step 2, Advanced Pharmacological Management: Centered on the use of oral COX-2 selective or non-selective NSAIDs for patients with persistent symptoms, adding intra-articular hyaluronic acid (IAHA) or corticosteroid injections if additional symptom relief is needed.

Step 3, Final Pharmacological Attempts: These include weak opioids, such as tramadol, prescription NSAIDs, and other central analgesics as a last resort before surgery.

Step 4, End-stage Disease Management: Total knee replacement or classical opioids as an alternative when surgery is contraindicated. Transcutaneous Electric Nerve Stimulation (TENS) and acupuncture are listed as “considerations” if a patient is unwilling to undergo surgery or it is contraindicated

Recommendations in the ESCEO plan largely echo guidelines for managing knee OA issued by the OA Research Society International (OARSI) reported earlier this year. However, the OARSI guidelines did not support the use of IAHA and called the evidence for glucosamine “uncertain.” (The report notes that prescription formulations of glucosamine sulfate are not available in the US, and that the US Food and Drug Administration does not regulate the medical quality of supplements of this kind.)