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PANLAR Consensus Recommendations for the Management in Osteoarthritis of Hand, Hip, and Knee

Rillo, Oscar MD; Riera, Humberto MD, PhD; Acosta, Carlota MD; Liendo, Verónica MD; Bolaños, Joyce MD; Monterola, Ligia MD; Nieto, Edgar MD; Arape, Rodolfo MD; Franco, Luisa M. MD; Vera, Mariflor MD; Papasidero, Silvia MD; Espinosa, Rolando MD; Esquivel, Jorge A. MD; Souto, Renee MD; Rossi, Cesar MD; Molina, José F. MD; Salas, José MD; Ballesteros, Francisco MD; Radrigan, Francisco MD; Guibert, Marlene MD; Reyes, Gil MD; Chico, Araceli MD; Camacho, Walter MD; Urioste, Lorena MD; Garcia, Abraham MD; Iraheta, Isa MD; Gutierrez, Carmen E. MD; Aragón, Raúl MD; Duarte, Margarita MD; Gonzalez, Margarita MD; Castañeda, Oswaldo MD; Angulo, Juan MD; Coimbra, Ibsen MD; Munoz-Louis, Roberto MD; Saenz, Ricardo MD; Vallejo, Carlos MD; Briceño, Julio MD; Acuña, Ramón P. MD; De León, Anibal MD; Reginato, Anthony M. MD, PhD; Möller, Ingrid MD; Caballero, Carlo V. MD, PhD; Quintero, Maritza MD, PhD

JCR: Journal of Clinical Rheumatology: October 2016 - Volume 22 - Issue 7 - p 345–354
doi: 10.1097/RHU.0000000000000449
Original Articles

Objective The objective of this consensus is to update the recommendations for the treatment of hand, hip, and knee osteoarthritis (OA) by agreeing on key propositions relating to the management of hand, hip, and knee OA, by identifying and critically appraising research evidence for the effectiveness of the treatments and by generating recommendations based on a combination of the available evidence and expert opinion of 18 countries of America.

Methods Recommendations were developed by a group of 48 specialists of rheumatologists, members of other medical disciplines (orthopedics and physiatrists), and three patients, one for each location of OA. A systematic review of existing articles, meta-analyses, and guidelines for the management of hand, hip, and knee OA published between 2008 and January 2014 was undertaken. The scores for Level of Evidence and Grade of Recommendation were proposed and fully consented within the committee based on The American Heart Association Evidence-Based Scoring System. The level of agreement was established through a variation of Delphi technique.

Results Both “strong” and “conditional” recommendations are given for management of hand, hip, and knee OA and nonpharmacological, pharmacological, and surgical modalities of treatment are presented according to the different levels of agreement.

Conclusions These recommendations are based on the consensus 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. Different backgrounds in terms of patient education or drug availability in different countries were not evaluated but will be important.

From the *Servicio de Reumatología del Hospital Ignacio Pirovano, Buenos Aires, Argentina; †Instituto Autónomo Hospital Universitario de Los Andes, Universidad de Los Andes, Mérida, Venezuela; ‡Complejo Hospitalario Universitario “Ruiz y Páez”, Ciudad Bolívar, Venezuela; §Unidad de Investigación Reumatológica, Clínica Félix Boada, Caracas, Venezuela; ∥Hospital Pérez Carreño, Caracas, Venezuela; ¶Clínica Colinas, Anzoátegui, Venezuela; #Instituto Autónomo Hospital Universitario de Los Andes, Servicio de Traumatología, Universidad de Los Andes, Mérida, Venezuela; **Centro Clínico La Isabelica, Carabobo, Venezuela; ††Instituto Docente de Urología, Valencia, Venezuela; ‡‡LabMice, Universidad de Los Andes, Mérida, Venezuela; §§Departamento de Reumatología, ∥∥Instituto Nacional de Rehabilitación, Ciudad de México, México ; ¶¶Departamento de Medicina Interna, Servicio de Reumatología, Universidad Autónoma de Nuevo León, Nuevo León, México; ##Cátedra de Reumatología de la Facultad de Medicina de la Universidad de la Republica, Montevideo, Uruguay; ***Arthritis Clinical Research Unit at Medicarte, Medellin, Colombia; †††Grupo de Reumatólogos del Caribe, Barranquilla, Colombia; ‡‡‡Departamento de Reumatología, Universidad Católica de Chile, Santiago, Chile; §§§Servicio de Reumatología, Hospital Quirúrgico 10 de Octubre, Cerro, La Habana, Cuba; ∥∥∥Servicio de Reumatología, Hospital Hermanos Ameijeiras and Servicio de Reumatología del Hospital Clínico Quirúrgico Hermanos Ameijeiras, La Habana, Cuba; ¶¶¶Servicio de Reumatología Hospital Santa Cruz, Caja Petrolera de Salud Techo Académico Universidad Católica, San Pablo, Bolivia; ###Servicio de Reumatología Kolping y Hospital Alfonzo Gumucio-Techo Académico Universidad Católica, San Pablo, Bolivia; ****Post-Grado de Reumatología, AGAR, FM, UFM, Facultad de Medicina, Universidad Francisco Marroquín, Guatemala City, Guatemala; ††††Servicio de Reumatología, Instituto Salvadoreño del Seguro Social, San Miguel, El Salvador; ‡‡‡‡Facultad de Medicina, Universidad de El Salvador, San Salvador, El Salvador; §§§§Servicio de Reumatología del Hospital de Clínicas de Asunción, Universidad Nacional de Asunción, Asunción, Paraguay; ∥∥∥∥Servicio de Reumatología, Hospital San Ramón, Santa Rita, Paraguay; ¶¶¶¶Universidad Peruana de Ciencias Aplicadas UPC and Servicio Reumatología, British American Hospital, Lima, Peru; ####Universidad Nacional Mayor de San Marcos, Lima, Peru; *****Departamento de Clínica Médica da Faculdade de Ciências Médicas da UNICAMP—Universidade Estadual de Campinas, São Paulo, Brazil; †††††Servicio de Reumatología, Hospital Docente Padre Billini, Clínica Abreu, Santo Domingo, Dominican Republic; ‡‡‡‡‡Servicio de Reumatología. Hospital Dr. Rafael A. Calderón Guardia, San José, Costa Rica; §§§§§Facultad de Medicina, Pontificia Universidad Católica del Ecuador, Quito, Ecuador; ∥∥∥∥∥Unidad de Reumatología, Hospital Central de Managua, Managua, Nicaragua; ¶¶¶¶¶Hospital Especializado Dr. Arnulfo Arias Madrid, Panama, Panama; #####Hospital Santo Tomás, Panama, Panama; ******Division of Rheumatology, The Warren Alpert School of Medicine, Providence, RI, USA; ††††††Universidad de Barcelona, Instituto Poal, Barcelona, Spain; and ‡‡‡‡‡‡Universidad del Norte, Barranquilla, Colombia.

The authors declare no conflict of interest.

Disclosure of funding: This study was conducted with funding from PANLAR.

Correspondence: Maritza Quintero, PhD, MD, Universidad de Los Andes, Laboratory of Rheumatic Diseases at IAHULA, Osteoarthritis Group—PANLAR (Liga Panamericana de Reumatología), Instituto Autónomo Hospital Universitario de Los Andes, Unidad de Reumatología, Facultad de Medicina, Universidad de Los Andes, Av 16 de septiembre, Mérida 5101, Venezuela. E-mail: maritzaquintero@gmail.com.

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.

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METHODS

Literature Research

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

TABLE 1

TABLE 1

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.

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Participants

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.

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Experts’ Consensus

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.

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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.

TABLE 2

TABLE 2

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

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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

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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

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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

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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.

TABLE 3

TABLE 3

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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).

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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

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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).

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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.

TABLE 4

TABLE 4

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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

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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…).

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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

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DISCUSSION

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.

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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.

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CONCLUSIONS

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.

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ACKNOWLEDGMENT

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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                                                                                                                                              Keywords:

                                                                                                                                              osteoarthritis of the hand, hip, and knee; consensus recommendations

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