G. Herrero, Rheumatologist, Fundaçion Jimenez Diza, Madrid, Spain
In the final stage of the treatment recommendations for osteoarthritis, the experts drew up proposals and decided arbitrarily to provide 10 recommendations outlining their position.
These are based on the personal experience of each expert on the one hand, and the efficacy and toxicity of each drug regimen on the other.
The experts validated the results by a bibliographical search on numerous studies according to their quality and level of proof. The safety profile of each treatment was prepared by the experts taking into consideration the results of a previous evaluation of the level of toxicity on a visual analogue scale.
A second series of 10 recommendations was defined for the purpose of establishing research projects on osteoarthritis.
The Delphi method was used to reach a final consensus. In the first instance each expert was asked to offer synthetic phrases deemed important enough to be included in the final recommendations.
All these recommendations were put together:
104 related to treatments and 109 to research projects. They were returned to the experts asking them to rank the 10 most important proposals to be considered in the final recommendations.
In the second stage, only the items that were approved by at least 66% of the experts were selected (25 treatment proposals and 24 proposals for research projects). After a total of five stages using the same methodology, the 10 most crucial phrases in each section were retained.
The recommendations for treating osteoarthritis are thus the following:
1. Optimal management of knee osteoarthritis requires a combination of a non-drug and drug treatment.
2. Treatment of osteoarthritis of the knee should be determined based on:
a) Risk factors for the knee (obesity, negative mechanical factors, physical activity)
b) General risk factors (age, comorbidity, polymedication)
c) The level of pain and disability
d) Signs of inflammation (e.g. effusion)
e) The location and extent of structural damage
3. The non pharmacological treatment should include regular monitoring, exercise, therapeutic equipment (sticks, insoles) and weight loss.
4. Topical applications (NSAID, capsaicin) have clinical efficacy and are safe.
5. In patients with an increased gastrointestinal risk, a non-selective NSAID with a gastroprotective agent or a COX-2 specific inhibitor should be used.
6. Opioid analgesics are useful alternatives for patients in whom NSAIDs and Cox II selective inhibitors are contraindicated, ineffective and / or poorly tolerated.
7. Glucosamine sulfate, chondroitin sulfate, and soya bean and avocado unsaponifiables, diacerhein and hyaluronic acid have a symptomatic effect and can have a structural effect.
8. The intra-articular injection of a long-term corticosteroid is indicated in cases of pain in knee erythematosus especially when the pain is accompanied by an effusion.
9. A joint prosthesis should be considered in patients with X-rays showing osteoarthritis of the knee with pain resistant to treatment and disability.
The final recommendations included in the guidelines for osteoarthritis research projects and treatments will be discussed at a future session.
Based on a bibliographical search and the opinion of the experts, a set of 10 recommendations for the treatment of OA was developed according to the Delphi technique on 5 levels. Another series of 10 recommendations also defined by the Delphi technique on 5 levels was used to set up a research project on knee osteoarthritis.
Jordan K et coll., "EULAR Recommendations 2003", Ann. Rheum. 62. 1145-55, 2003; International Journal of Medicine, January 2004; www.eular.org