Osteoarthritis Guidelines Research Articles

SP0178 Implementation of OA Care Path Ways in Sweden: Better Management of Osteoarthritis (BOA)

Information, exercise and weight reduction are recommended as first line treatment for patients with hip or knee osteoarthritis (OA) whereas only a minority of OA patients are eligible for surgical...

Cost-Utility Analysis of Duloxetine in Osteoarthritis: A US Private Payer Perspective

Duloxetine has recently been approved in the USA for chronic musculoskeletal pain, including osteoarthritis and chronic low back pain. The cost effectiveness of duloxetine in osteoarthritis has not previously been assessed. Duloxetine is targeted as post first-line (after acetaminophen) treatment of moderate to severe pain. The objective of this study was to estimate the cost effectiveness of duloxetine in the treatment of osteoarthritis from a US private payer perspective compared with other post first-line oral treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs), and both strong and weak opioids. A cost-utility analysis was performed using a discrete-state, time-dependent semi-Markov model based on the National Institute for Health and Clinical Excellence (NICE) model documented in its 2008 osteoarthritis guidelines. The model was extended for opioids by adding titration, discontinuation and additional adverse events (AEs). A life-long time horizon was adopted to capture the full consequences of NSAID-induced AEs. Fourteen health states comprised the structure of the model: treatment without persistent AE, six during-AE states, six post-AE states and death. Treatment-specific utilities were calculated using the transfer-to-utility method and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores from a meta-analysis of osteoarthritis clinical trials of 12 weeks and longer. Costs for 2011 were estimated using Red Book, The Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project database, the literature and, sparingly, expert opinion. One-way and probabilistic sensitivity analyses were undertaken, as well as subgroup analyses of patients over 65 years old and a population at greater risk of NSAID-related AEs. In the base case the model estimated naproxen to be the lowest total-cost treatment, tapentadol the highest cost, and duloxetine the most effective after considering AEs. Duloxetine accumulated 0.027 discounted quality-adjusted life-years (QALYs) more than naproxen and 0.013 more than oxycodone. Celecoxib was dominated by naproxen, tramadol was subject to extended dominance, and strong opioids were dominated by duloxetine. The model estimated an incremental cost-effectiveness ratio (ICER) of US$47,678 per QALY for duloxetine versus naproxen. One-way sensitivity analysis identified the probabilities of NSAID-related cardiovascular AEs as the inputs to which the ICER was most sensitive when duloxetine was compared with an NSAID. When compared with a strong opioid, duloxetine dominated the opioid under nearly all sensitivity analysis scenarios. When compared with tramadol, the ICER was most sensitive to the costs of duloxetine and tramadol. In subgroup analysis, the cost per QALY for duloxetine versus naproxen fell to US$24,125 for patients over 65 years and to US$18,472 for a population at high risk of cardiovascular and gastrointestinal AEs. The model estimated that duloxetine was potentially cost effective in the base-case population and more cost effective for subgroups over 65 years or at high risk of NSAID-related AEs. In sensitivity analysis, duloxetine dominated all strong opioids in nearly all scenarios.

Osteoarthritis guidelines: a progressive role for topical nonsteroidal anti-inflammatory drugs

Current treatment guidelines for the treatment of chronic pain associated with osteoarthritis reflect the collective clinical knowledge of international experts in weighing the benefits of pharmacologic therapy options while striving to minimize the negative effects associated with them. Consideration of disease progression, pattern of flares, level of functional impairment or disability, response to treatment, coexisting conditions such as cardiovascular disease or gastrointestinal disorders, and concomitant prescription medication use should be considered when creating a therapeutic plan for a patient with osteoarthritis. Although topical nonsteroidal anti-inflammatory drugs historically have not been prevalent in many of the guidelines for osteoarthritis treatment, recent evidence-based medicine and new guidelines now support their use as a viable option for the clinician seeking alternatives to typical oral formulations. This article provides a qualitative review of these treatment guidelines and the emerging role of topical nonsteroidal anti-inflammatory drugs as a therapy option for patients with localized symptoms of osteoarthritis who may be at risk for oral nonsteroidal anti-inflammatory drug-related serious adverse events.

A systematic review of the literature on best practice and quality of care for patients with osteoarthritis in the setting of diabetes or cardiovascular disease

Purpose: The management of osteoarthritis (OA) is challenging in patients who also have other medical conditions, which may be perceived as precluding the safe use of OA therapies. We conducted a systematic review of the literature to identify and evaluate studies that addressed best practice or quality of OA care in the setting of diabetes (DM) and/or cardiovascular disease (CVD). Methods: Two reviewers independently reviewed titles and abstracts of publications identified via a comprehensive search of electronic databases (MEDLINE, EMBASE, and CINAHL) between January 2000 and February 2011 and citation lists. Articles addressing the management of OA in the presence of DM or CVD (or vice versa) were included. Results: 8334 articles were identified through the search process, 41 were selected for full-text review and 32 were included after discussion. Only 10 of the 32 identified studies (31%) discussed strategies to improve OA management in the setting of comorbid DM and/or CVD. Five studies recommended cautious prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase (COX)-2 inhibitors in patients with CVD or CV risk factors. One study recommended naproxen for treatment of OA in the setting of DM and CVD; another recommended acetaminophen with or without codeine in the setting of hypertension (HTN). Three studies recommended only non-pharmacological approaches. Six of 32 studies (19%) documented pharmacological under-treatment of one condition in the presence of another (use of NSAIDs and overall treatment for OA in CVD/DM; treatment of HTN in OA). 3 studies showed no differences in prescribing patterns. Eight studies (25%) documented a negative impact of OA on outcomes for CVD/DM (recovery from stroke, hospitalization for congestive heart failure and physical activity/self-management). Three qualitative studies identified comorbid OA as a barrier to care for CVD/DM. Three studies documented the non-applicability of single-disease clinical practice guidelines to the management of patients with multiple conditions, including OA guidelines in the setting of CVD/DM. Only one study evaluated the influence of either DM or CVD on quality of care for OA using established quality indicators. In 90 individuals with OA, the mean OA-specific quality score was 42.6% (the proportion of recommended care received) compared with an overall mean quality score of 54.9% for all conditions combined. No study provided evidence-based recommendations for OA management in individuals with comorbid DM or CVD. Conclusions: Despite the high co-prevalence of DM and CVD in people with painful OA, and the documented under-treatment of OA in the presence of these comorbidites, there is little information on best practice for the management of OA in the setting of other common chronic conditions. Evidence-informed practice recommendations are urgently needed to support the care of this group of patients.

Tips for GP trainees working in rheumatology

One in four people registered with a GP will consult for a musculoskeletal problem over a 12-month period; this accounts for one in seven GP consultations.1 Musculoskeletal conditions significantly impact daily life through pain, disability, and psychological ill-health.2,3 A rheumatology rotation is therefore a relevant and practical rotation for GP trainees to undertake. The key learning points from a rheumatology rotation include the early recognition of inflammatory arthritis to enable timely secondary care referral, the identification of the red flags of joint sepsis, and development of an understanding of the social and psychological consequences of chronic musculoskeletal conditions. 1. 1. Before your first day, read current guidelines relating to common rheumatological conditions in both primary and secondary care, for example, the NICE guidelines for osteoarthritis and rheumatoid arthritis.4,5 2. 2. Practice your examination skills. Although you are likely to be an experienced junior doctor, asking a friendly registrar to demonstrate their slick examination style and asking for tips will save you a lot of time in the future when clerking inpatients and outpatients. 3. 3. Learn the monitoring requirements and side effects of the commonly used disease-modifying antirheumatic drugs. …

Implementing the NICE Osteoarthritis Guidelines in Primary Care: A Role for Practice Nurses

Implementing the NICE Osteoarthritis Guidelines in Primary Care: A Role for Practice Nurses

Developing a model osteoarthritis consultation: a Delphi consensus exercise

BackgroundOsteoarthritis (OA) is a common condition managed in general practice, but often not in line with published guidance. The ideal consultation for a patient presenting with possible OA is not known. The aim of the study was to develop the content of a model OA consultation for the assessment and treatment of older adults presenting in general practice with peripheral joint problems.MethodsA postal Delphi consensus exercise was undertaken with two expert groups: i) general practitioners (GPs) with expertise in OA management and ii) patients with experience of living with OA. An advisory group generated 61 possible consultation tasks for consideration in the consensus exercise. Expert groups were asked to consider which tasks should be included in the model OA consultation. The exercise was completed by 15 GPs and 14 patients. The level of agreement for inclusion in the model was set at 90%.ResultsThe model OA consultation included 25 tasks to be undertaken during the initial consultation between a GP and a patient presenting with peripheral joint pain. The 25 tasks provide detailed advice on how the following elements of the consultation should be addressed: i) assessment of chronic joint pain, ii) patient’s ideas and concerns, iii) exclusion of red flags, iv) examination, v) provision of the diagnosis and written information, vi) promotion of exercise and weight loss, vii) initial pain management and viii) arranging a follow-up appointment. Both groups prioritised a bio-medical approach to the consultation, rather than a bio-psycho-social one, suggesting a discordance between current thinking and research evidence.ConclusionsThis study has enabled the priorities of GPs and patients to be identified for a model OA consultation. The results of this consensus study will inform the development of best practice for the management of OA in primary care and the implementation of evidence-based guidelines for OA in primary care.

Prescribing Optimal Nutrition and Physical Activity as “First-Line” Interventions for Best Practice Management of Chronic Low-Grade Inflammation Associated with Osteoarthritis: Evidence Synthesis

Low-grade inflammation and oxidative stress underlie chronic osteoarthritis. Although best-practice guidelines for osteoarthritis emphasize self-management including weight control and exercise, the role of lifestyle behavior change to address chronic low-grade inflammation has not been a focus of first-line management. This paper synthesizes the literature that supports the idea in which the Western diet and inactivity are proinflammatory, whereas a plant-based diet and activity are anti-inflammatory, and that low-grade inflammation and oxidative stress underlying osteoarthritis often coexist with lifestyle-related risk factors and conditions. We provide evidence-informed recommendations on how lifestyle behavior change can be integrated into “first-line” osteoarthritis management through teamwork and targeted evidence-based interventions. Healthy living can be exploited to reduce inflammation, oxidative stress, and related pain and disability and improve patients' overall health. This approach aligns with evidence-based best practice and holds the promise of eliminating or reducing chronic low-grade inflammation, attenuating disease progression, reducing weight, maximizing health by minimizing a patient's risk or manifestations of other lifestyle-related conditions hallmarked by chronic low-grade inflammation, and reducing the need for medications and surgery. This approach provides an informed cost effective basis for prevention, potential reversal, and management of signs and symptoms of chronic osteoarthritis and has implications for research paradigms in osteoarthritis.

Latest Osteoarthritis Guidelines Address Benefits of Exercise

Latest Osteoarthritis Guidelines Address Benefits of Exercise

Inconsistencies in Nice Guidance for Acupuncture: Reanalysis and Discussion

Acupuncture received a positive recommendation in the National Institute for Health and Clinical Excellence (NICE) clinical guideline for low back pain (LBP). However, no such recommendation was forthcoming in the NICE clinical guideline for osteoarthritis (OA). Importantly, the two guidelines adopted different treatment comparators in their economic analyses of acupuncture; in the LBP guideline 'usual care' was used (with no consideration of placebo/sham interventions), whereas 'sham acupuncture' was the comparator in the OA guideline. To analyse the implications of using different control group comparators when estimating the cost-effectiveness of acupuncture therapy. The NICE OA economic analysis for acupuncture was replicated using 'usual care' (ie, no placebo/sham component) as the treatment comparator. A 'transfer-to-utility' technique was used to transform Western Ontario and McMaster Osteoarthritis scores into EQ-5D utility scores to allow quality-adjusted life year (QALY) gains to be estimated. QALY estimates were combined with direct incremental cost estimates of acupuncture treatment to determine incremental cost-effectiveness ratios (ICERs). When 'usual care' was used as the treatment comparator, ICER point estimates were below £20 000 per QALY gained for each acupuncture trial analysed in the OA clinical guideline. In the original analysis, using placebo/sham acupuncture as the treatment comparator, ICERs were generally above £20 000 per QALY gained. The treatment comparator chosen in economic evaluations of acupuncture therapy is likely to be a strong determinant of the cost-effectiveness results. Different comparators used in the OA and LBP NICE guidelines may have led to the divergent recommendations in the guidelines.

Group Acupuncture for Osteoarthritis; a Practical Option?

Knee pain due to osteoarthritis is an increasing health problem.1 ,2 Acupuncture is a promising treatment for osteoarthritis that may provide symptom relief without the adverse cardiovascular events associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs). When the UK National Institute of Health and Clinical Excellence (NICE) reviewed the evidence for its 2008 osteoarthritis guideline,3 they concluded that it seemed likely that acupuncture can provide some short-term to medium-term relief for some people living with osteoarthritis. However, in contrast with NICE back pain guidance,4 they did not make a positive recommendation for acupuncture. Importantly, as reported in one of the linked papers,5 the approach to the health economic analysis in the NICE osteoarthritis guideline compared verum and sham acupuncture whereas the NICE back pain guideline compared acupuncture with usual care. The Osteoarthritis Research Society International has recommended that ‘acupuncture may be of symptomatic benefit’6 and a subsequent Cochrane review of acupuncture7 concluded that there were small benefits from acupuncture when …

Osteoarthritis guidelines take balanced approach to therapy

New guidelines from the American College of Rheumatology (ACR) recommend both drug therapy and non-pharmacologic interventions for patients with osteoarthritis of the hand, hip, or knee. In developing the guidelines, ACR enlisted a diverse group of practitioners to examine the scientific evidence

Condylar bony changes in patients with temporomandibular disorders: a CBCT study

PurposeDiagnosis of osteoarthritis most commonly depends on clinical and radiographic findings. The present study attempted to observe the bony changes in temporomandibular joint (TMJ) patients from all age groups.Materials and MethodsThe first-visit clinical records and cone beam computed tomography (CBCT) data of 440 TMJs from 220 consecutive TMJ patients were reviewed retrospectively.ResultsThe most frequent condylar bony change observed was sclerosis (133 joints, 30.2%) followed by surface erosion (129 joints, 29.3%), flattening of the articular surface (112 joints, 25.5%), and deviation in form (58 joints, 13.2%), which included 33 TMJs in a cane-shape, 16 with a lateral or medial pole depression, 6 with posterior condylar surface flattening, and 3 with a bifid-shaped condyle. Fifty-three joints (12.0%) showed hypoplastic condyles but only 1 joint showed hyperplasia. Osteophyte was found in 35 joints (8.0%) and subcortical cyst in 24 joints (5.5%), 5 of which had surface erosion as well. One hundred nineteen joints (27.0%) had only one kind of condylar bony change, 66 joints (15.0%) had two, 52 joints (11.8%) had three, 12 joints (5.0%) had four, and 6 joints (1.4%) had five kinds of condylar bony changes at the same time. Eighty-five (65.9%) of 129 joints with surface erosion had pain recorded at the chief complaint.ConclusionWith more widespread use of CBCT, more specific or detailed guidelines for osteoarthritis are needed.

Development of a brief multidisciplinary education programme for patients with osteoarthritis

BackgroundOsteoarthritis (OA) is a prevalent progressive musculoskeletal disorder, leading to pain and disability. Patient information and education are considered core elements in treatment guidelines for OA; however, there is to our knowledge no evidence-based recommendation on the best approach, content or length on educational programmes in OA. Objective: to develop a brief, patient oriented disease specific multidisciplinary education programme (MEP) to enhance self-management in patients with OA.MethodTwelve persons (80% female mean age 59 years) diagnosed with hand, hip or knee OA participated in focus group interviews. In the first focus group, six participants were interviewed about their educational needs, attitudes and expectations for the MEP. The interviews were transcribed verbatim and thereafter condensed.Based on results from focus group interviews, current research evidence, clinical knowledge and patients' experience, a multidisciplinary OA team (dietist, nurse, occupational therapist, pharmacist, physical therapist and rheumatologist) and a patient representative developed a pilot-MEP after having attended a work-shop in health pedagogics. Finally, the pilot-MEP was evaluated by a second focus group consisting of four members from the first focus group and six other experienced patients, before final adjustments were made.ResultsThe focus group interviews revealed four important themes: what is OA, treatment options, barriers and coping strategies in performing daily activities, and how to live with osteoarthritis. Identified gaps between patient expectations and experience with the pilot-programme were discussed and adapted into a final MEP. The final MEP was developed as a 3.5 hour educational programme provided in groups of 6-9 patients. All members from the multidisciplinary team are involved in the education programme, including a facilitator who during the provision of the programme ensures that the individual questions are addressed. As part of an ongoing process, a patient representative regularly attends the MEP and gives feedback concerning content and perceived value.ConclusionA MEP has been developed to enhance self-management in patients with OA attending a multidisciplinary OA outpatient clinic. The effectiveness of the MEP followed by individual consultations with members of the multidisciplinary team is currently evaluated in a randomised controlled trial with respect to patient satisfaction and functioning.

Topical Therapies for Osteoarthritis

This review discusses the pharmacology, analgesic efficacy, safety and tolerability of topical NSAIDs, salicylates and capsaicin for the management of osteoarthritis (OA) pain. Topical therapies present a valuable therapeutic option for OA pain management, with substantial evidence supporting the efficacy and safety of topical NSAIDs, but less robust support for capsaicin and salicylates. We define topical therapies as those intended to act locally, in contrast to transdermal therapies intended to act systemically. Oral therapies for patients with mild to moderate OA pain include paracetamol (acetaminophen) and NSAIDs. Paracetamol has only weak efficacy at therapeutic doses and is hepatotoxic at doses >3.25 g/day. NSAIDs have demonstrated efficacy in patients with OA, but are associated with dose-, duration- and age-dependent risks of gastrointestinal, cardiovascular, renal, haematological and hepatic adverse events (AEs), as well as clinically meaningful drug interactions. To minimize AE risks, treatment guidelines for OA suggest minimizing NSAID exposure by prescribing the lowest effective dose for the shortest duration of time. Systemic NSAID exposure may also be limited by prescribing topical NSAIDs, particularly in patients with OA pain limited to a few superficial joints. Topical NSAIDs have been available in Europe for decades and were introduced to provide localized analgesia with minimal systemic NSAID exposure. Guidelines of the American Academy of Orthopaedic Surgeons, European League Against Rheumatism (EULAR), Osteoarthritis Research Society International, and National Institute for Health and Clinical Excellence (NICE) state that topical NSAIDs may be considered for patients with mild to moderate OA of the knee or hand, particularly in patients with few affected joints and/or a history of sensitivity to oral NSAIDs. In fact, the EULAR and NICE guidelines state that topical NSAIDs should be considered before oral therapies. Clinical trials of topical NSAIDs, most notably formulations of diclofenac and ketoprofen, have shown efficacy significantly superior to placebo and similar to oral NSAIDs. Most topical NSAIDs (piroxicam being the exception) have shown improved safety and tolerability compared with oral NSAIDs. Topical salicylates and capsaicin are available in the US without a prescription, but neither has shown substantial efficacy in clinical trials, and both have potential to cause serious AEs. Accidental poisonings have been reported with salicylates, and concerns exist that capsaicin-induced nerve desensitization is not fully reversible and that its autonomic nerve effects may increase the risk of skin ulcers in diabetic patients.

Lay models of self-management: how do people manage knee osteoarthritis in context?

Current NICE guidelines for Osteoarthritis (OA) identify several core self-management recommendations (exercise and weight loss if overweight/obese) to be supported by Healthcare Professionals. Contemporary research stresses that a patient-centred model of self-management that builds upon existing patient action and belief is essential. The lay beliefs regarding self-management for OA have not been explicitly explored previously. Of the participants, 22 people were recruited to undertake in-depth interviews and a diary study. The constant comparative method and narrative methods were utilized to analyse the data. Making adaptations and using strategies to get on with 'normal' daily life is as much a part of caring for OA as easing painful symptoms. Moreover, participants 'normal' routines ensured that they were able to stay active and keep the knee joint moving. Thus, maintaining everyday social roles and valued activities parallels recommendations from policy and practice. Engaging in exercise is influenced by biography, preferred lifestyle and contextual need. Practitioners and policy need to embrace the complexities of managing chronic OA conditions, by taking onboard the needs and priorities of patients. The findings highlight the disease specific needs of self-management that may be omitted from programmes like the Expert Patients Programme.

Osteoarthritis subpopulations and implications for clinical trial design

Treatment guidelines for osteoarthritis have stressed the need for research on clinical predictors of response to different treatments. However, identifying such clinical predictors of response is less easy than it seems, and there is not a given classification of osteoarthritis subpopulations. This review article highlights the key methodical issues when analyzing and designing clinical studies to detect important subgroups with respect to treatment effect. In addition, we discuss the main osteoarthritis subpopulations and give examples of how specific treatment effects in these subpopulations have been assessed.

Clinically Meaningful Relief of Osteoarthritis in Randomized Controlled Trials of Diclofenac Sodium 1% Gel

PURPOSE: To compare rates of clinically meaningful response in patients with hand and knee osteoarthritis (OA) treated with diclofenac sodium 1% gel (DSG) versus placebo rubefacient gel (PRG). Over-the-counter topical rubefacients are often used in sports medicine but have poor efficacy and are not recommended in evidence-based guidelines for OA (National Institute for Health and Clinical Excellence clinical guideline 59), whereas topical nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended ahead of oral NSAIDs. However, many US physicians lack experience with topical NSAIDs and may be skeptical that they offer meaningful benefit compared with more familiar topical rubefacients. METHODS: In a post hoc analysis, patients from 2 double-blind trials of DSG in knee or hand OA were classified based on Osteoarthritis Research Society International (OARSI) criteria for clinically significant response. Patients were randomized to apply DSG or PRG 4 times daily (hand, 8 g/d/hand for 8 weeks to 2 hands; knee, 16 g/d for 12 weeks to 1 knee). OARSI response was defined as improvement ≥50% and absolute change ≥20 points on 100-point scales measuring pain or physical function, or improvement ≥20% and absolute change ≥10 in ≥2 of the following: pain, global rating of disease, and physical function. RESULTS: Clinically significant improvement was achieved by 56%-71% of patients treating knee OA and hand OA with DSG, which was significantly superior to response rates with PRG at most time points (Table). CONCLUSIONS: DSG provided clinically meaningful improvement in OA pain for the majority of patients with hand or knee OA, and for a significantly greater proportion of patients compared with PRG. Supported by Endo Pharmaceuticals Inc.

Patient Preference for Sustained-Release versus Standard Paracetamol (Acetaminophen): A Multicentre, Randomized, Open-Label, Two-Way Crossover Study in Subjects with Knee Osteoarthritis

Guidelines for osteoarthritis (OA) management recommend paracetamol (acetaminophen) as the most appropriate first-line analgesic for mild to moderate pain. Standard paracetamol requires four times daily dosing. Drug compliance and convenience are inversely related to daily dose frequency. Compliance is a pivotal component of the successful management of OA pain and is influenced by patient preferences or beliefs. The added convenience of three times daily dosing may enhance compliance and, therefore, pain relief. This multicentre, randomized, open-label, two-way crossover, phase IV study is the first to evaluate patient preference with a sustained-release paracetamol tablet formulation designed for three times daily dosing. Compared with standard paracetamol tablets dosed four times daily, the sustained-release formulation was preferred in a 2:1 ratio, provided better overall joint pain relief, resulted in higher levels of satisfaction in subjects with OA of the knee and has the potential to improve patient compliance and, therefore, pain control.

Nice Guideline on Osteoarthritis: Is it Fair to Acupuncture? Yes

The NICE Osteoarthritis Guideline Development Group (GDG) has been challenged for not using the available acupuncture evidence in the most appropriate manner in three crucial areas. This response explains the methods used by the GDG with particular reference to the economic analysis, and illustrates that the methods used were those most appropriate for developing a NICE clinical guideline. The cost-effectiveness conclusions made by the GDG are supported by the currently available evidence.