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Cures for knee OA remain elusive.
If all else fails, replace EULAR
recommendations make choosing OA drugs, or any therapy,
like target practice
By Maria Turner
"There is no single right
and wrong approach and each health professional must
decide with each patient the most appropriate management
plan at a particular time and for that location," concluded
the European League Against Rheumatism (EULAR). The
newest guidelines appeared in a recent issue of Annals
of Rheumatic Disease.
The 2003 recommendations
are based on the committee's review of the literature
on 33 identified treatment modalities and include a
total of 545 publications up to the year 2002. The recommendations
do not differ significantly from those published in
2000, but include some modifications and new propositions.
Researchers say that evidence
for the use of many symptomatic slow-acting drugs for
osteoarthritis (OA) is weak or absent, but they do conclude
that there is growing evidence to support the use of
glucosamine sulphate and chondroitin sulphate for their
symptomatic effects. Although they also mention that
hyaluronic acid may be helpful in both pain reduction
and functional improvement, they suggest that logistics
and cost may be factors in the use of this treatment.
In cases of severe disease,
total knee replacement is recommended for patients for
whom other treatments have failed.
THE
TEN RECOMMENDATIONS
- The optimal management of knee OA requires a combination
of non-pharmacological and pharmacological treatment
modalities.
- The treatment of knee
OA should be tailored to: knee risk factors (obesity,
adverse mechanical factors, physical activity); general
risk factors (age, comorbidity, polypharmacy); level
of pain intensity and disability; sign of inflammation
(eg, effusion); and location and degree of structural
damage.
- Non-pharmacological therapy
of knee OA should include education, exercise, appliances
(sticks, insoles, knee bracing) and weight reduction.
- Acetaminophen is the oral
analgesic to try first and, if successful, the preferred
long-term oral analgesic.
- Topical applications (NSAID,
capsaicin) clinically efficacious and are safe.
- NSAIDs should be considered
in patients unresponsive to acetaminophen. In those
with an increased gastrointestinal risk, nonselective
NSAIDs and effective gastroprotective agents, or selective
COX-2 inhibitors, should be used.
- Opioid analgesics, with
or without acetaminophen, are useful alternatives
for patients in whom NSAIDs, including COX-2 inhibitors,
are contraindicated, ineffective or poorly tolerated.
- SYSADOA (glucosamine,
chondroitin, ASU, diacerein, hyaluronic acid) have
symptomatic effects and may modify structure.
- Intra-articular injection
of long-acting corticosteroid is indicated for flare
of knee pain, especially if accompanied by effusion.
- Joint replacement has
to be considered in patients with radiographic evidence
of knee OA who have refractory pain and disability.
Researchers suggest an individualized
approach to applying the recommendations, underlining
that the findings of the review show that there are
many different treatment options for knee osteoarthritis.
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