Osteoarthritis (OA) is the most common type of rheumatic disease; it is one of the main reasons for presentation to a rheumatologist. As the second most common cause of work disability after cardiovascular disease, OA incurs direct and indirect costs that have a major impact on the world economy and health systems.1,2
The reported prevalence of OA ranges from 0.5 to 40% of the general population. The wide variation is attributed to the variability of the clinical features of the disease and the different criteria used for diagnosis.1,2 Multiple patient factors are associated with an increased risk of OA, with age being the most important, followed by gender, body mass index, and microtraumas.3–6 This consensus derives from a previous study of Demographic and Clinical Characteristics of 3040 Patients by the PANLAR OA study group, reporting significant differences in handling these patients and the need for reaching an agreement in the management of OA in Latin America, taking into account the conditions of this region.7
As there is a lack of standardized criteria for the treatment of OA, the objective of this committee of experts was to obtain agreement on OA treatment and to provide recommendations for the three most common joints affected by OA: the hand, hip, and knee.
A group specialized in literature research performed a review of the literature available from 2008 to 2014 in MEDLINE, PubMed (National Center for Biotechnology Information, Bethesda, MD, USA), Cochrane Library (John Wiley & Sons, Inc., NJ, USA), and Embase (Elsevier, Madrid, Spain). The level of evidence and strength of recommendation were evaluated as shown in Table 1, which were proposed and fully consented within the committee based on The American Heart Association Evidence-Based Scoring System.8
A total of 896 articles were selected for analysis. The articles were classified according to the model proposed by the Center for Evidence-Based Medicine at Oxford, UK or the Jadad scale.9 Using these criteria, 108 articles were selected, and individual responses to questions developed through the analysis of the evidence available in the literature were given by the committee of experts.
Forty-eight experts in the field of OA (rheumatologists, orthopedic surgeons, and physical medicine specialties and OA patients and a general coordinator) representing 18 Latin American countries agreed to take part in this study.
Two sessions were conducted with the aim of reaching agreement on the final recommendations for OA in all three joints. Each participant was asked to contribute independently with questions related to key clinical aspects in the management of hand, hip, and knee OA. The consensus was reached by using a variation of the Delphi technique. The experts answered questionnaires in three rounds. After each round, a facilitator provided an anonymous summary of the experts’ forecasts from the previous round and the reasons they provided for their judgments. The experts revised their earlier answers in light of the replies of other members of their panel.
Upon completion of the expert opinions, the document was edited by the Editorial Committee with the final texts approved by members of the working groups.
Recommendations for Hand OA
The recommendations for the management of hand OA are summarized in Table 2 together with the level of evidence supporting them. The treatment propositions are categorized into nonpharmacological, pharmacological, and surgical treatment modalities.
The treatment of hand OA should be individualized according to the type of OA (nodal or erosive), its location and severity, the presence of inflammation, the pain level, the level of disability and reduction in quality of life, the comorbidities and concomitant medication, and the needs and expectations of patients.10–15
Nonpharmacological Treatment Modalities
Education with regard to joint protection should be provided (how to avoid adverse mechanical factors) together with an exercise regimen that includes muscle strengthening and range-of-motion exercises (IC).14–17 Furthermore, the combination of an orthosis (splint) with an exercise regimen to improve pain and functionality in the short and long term and an exercise regimen has been shown to decrease pain and increase the range of motion and strength in hand OA.10,14,16–27
Pharmacological Treatment Modalities
Pharmacological modalities of treatment include the use of topical NSAIDs, acetaminophen/paracetamol, and oral NSAIDs. Topical NSAIDs are indicated as being effective and safe for mild to moderate pain, and they are also indicated in elderly patients with mild to moderate persistent pain. For long-term treatment of hand OA, acetaminophen/paracetamol is the preferred oral analgesic. Other treatments in hand OA include the use of chondroitin sulfate for pain relief and function and the use of glucosamine and chondroitin sulfate. Furthermore, the use of steroids or intra-articular hyaluronic acid may be considered for use in the treatment of OA of the symptomatic TMC joint.28,29,41
Surgical Treatment Modalities
Surgery (trapeziectomia, arthroplasty with ligament reconstruction and tendon interposition, or arthrodesis) may be considered for severe OA of the base of the first finger (rhizarthrosis) in patients who have severe pain and/or disability and after conservative treatment has failed (IIbB).53–60 Proper use of arthroplasty or arthrodesis for the affected joints requires careful consideration of the needs of the patient with regard to the affected fingers.55–60
Recommendations for Hip OA
The recommendations for the management of hip OA are summarized in Table 3 together with the level of evidence supporting them. The treatment propositions are categorized into nonpharmacological, pharmacological, and surgical treatment modalities.
Nonpharmacological Treatment Modalities
Early rehabilitation is indicated to maintain mobility and prevent impairment of the extension and abduction function of the hip. Patients with hip OA should receive information and education regarding the therapeutic objectives and the importance of changes in lifestyle, which include an exercise regimen, weight reduction, the use of walking aids (walking stick and crutches) and shoe adjustments, and other measures to prevent the progression of joint damage.62–64
Available treatment options for pain relief in patients with hip OA include thermotherapy and transcutaneous electrical nerve stimulation (TENS).
Pharmacological Treatment Modalities
The use of acetaminophen/paracetamol is recommended for use in hip OA owing to its safety profile.65 NSAIDs may be indicated at higher than usual doses to treat more severe pain.61,66,67 The use of hyaluronic acid in the treatment of hip OA may be beneficial and, thus, could help to reduce NSAID use.70 In patients who suffer painful relapses and who do not respond to analgesics and NSAIDs, intra-articular corticosteroid injection (ultrasound-guided) may be beneficial to provide fast pain relief (IIaB).69,70
Surgical Treatment Modalities
The recommendations for the surgical treatment of hip OA are based on the available literature from the last 2 years.
Total hip arthroplasty is a surgical modality that is undergoing continuous development. It is indicated in patients who have OA accompanied by pain and difficulty walking and whose quality of life is impaired as it improves not only these factors but also patient survival.73,76 A variety of models and metal implants are available, and different approaches can be chosen such as the use of a cemented, uncemented, or hybrid prosthesis. The available evidence shows that cemented prostheses are as effective as uncemented, especially in the stem (femoral component), whereas uncemented prostheses are more effective for the cup (acetabular component).
Recommendations for Knee OA
The recommendations for the management of knee OA are summarized in Table 4 together with the level of evidence supporting them. The treatment propositions are categorized into nonpharmacological, pharmacological, and surgical treatment modalities.
Nonpharmacological Treatment Modalities
Information and education regarding treatment goals and the importance of lifestyle changes to reduce the degenerative damage of the knee joint should be provided to the patient. Use of support devices such as insoles and knee braces may help to reduce pain and stiffness.61,80,81
Pharmacological Treatment Modalities
A wide range of pharmacological treatment modalities is available for patients with knee OA, including acetaminophen/paracetamol, oral and topical NSAIDs, and tramadol. Furthermore, oral administration of hyaluronic acid may have a beneficial therapeutic effect in patients with symptomatic knee OA and may possibly have an even greater effect in relatively young patients.82 Treatment with chondroitin sulfate, which has a high safety profile, has been shown to have a beneficial effect on symptoms in patients with knee OA. In addition, it has been proven that this effect persists for 3 months after stopping the treatment (carryover effect). Recent studies have provided evidence that chondroitin sulfate use may delay OA progression.39,83–86 Moreover, the combined use of glucosamine and chondroitin sulfate is indicated in patients with knee OA and moderate to severe pain.98–100 Many other pharmacological treatment modalities are described in Table 4 (available only online only at…).
Surgical Treatment Modalities
Total knee arthroplasty may be indicated in the treatment of knee OA owing to its outstanding effect on pain and stiffness and the improvement obtained in physical activity 6 months after intervention.129,130 In patients with a partial rupture of the meniscus, a partial meniscectomy performed arthroscopically may be beneficial, followed by a physical therapy program.131,132
From the results of a recently published study7 of the PANLAR OA group, we found it important to have a consensus on the treatment of hand, hip, and knee OA that could fit the needs of patients and specialists in America because of the significant differences in handling these patients. Moreover, the need to ensure proper care with the least economic impact, in a region in which many countries have large gaps in financial resources, and there is an important clinical diversity and various educational and cultural levels, suggests specific adaptation to regional characteristics. These recommendations for the management of patients with hand, hip, and knee OA are based on the best available evidence of benefit, safety, and tolerability of nonpharmacologic and pharmacologic and surgical treatment modalities and the consensus judgment of clinical experts from a wide range of disciplines balancing the benefits and harms of these treatments and incorporating their preferences and values.
Differences With Regard to ACR, OARSI, and EULAR
Although there are other consensus and guidelines13,61,62,79 on the treatment of OA in the mentioned locations, this consensus focused on updating the information of the available modalities with the participation of the OA specialist and patients of 18 countries of America.
These recommendations are based on the consensus opinions of clinical experts from a wide range of disciplines taking available evidence into account while balancing the benefits and risks of nonpharmacological, pharmacological, and surgical treatment modalities, and incorporating their preferences and values. It is hoped that these recommendations will be utilized by healthcare providers involved in the management of patients with hand, hip, and knee OA.
The pharmacological management of OA has traditionally been centered on analgesics and NSAIDs; however, increasing toxicity warnings have been issued recently for paracetamol, traditional NSAIDs, and COX-2 inhibitors, making OA chronic treatment even more challenging. 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 suitable 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. On the other hand, the use of nonpharmacological treatments should also be taken into account due to the improvements that these may produce to the quality of life of the patient. Latin America is formed by different countries with background not similar to the European or North American countries in terms of patient education or drug availability. How conditions in different regions of Latin America will need consideration.
The authors thank Dr. Luis Espinoza, Dr. Antonio Jimenez, Dr. John Reveille, Dr. Carlos Pineda (PANLAR ex-presidents), and Dr. Joan Von Feldt. The authors also thank Ximena Sanchez and Rosa Sciortino for technical support.
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