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Osteoarthritis EULAR 2009
Figure 1: The Pyramidal Therapeutic Approach for These treatment modalities may be combined with intra-articular
Knee Osteoarthritis
steroids/hyaluronate and topical analgesics/NSAIDs. This pyramidal
therapeutic strategy is a proven and commonly used strategy that can
effectively control the signs and symptoms of OA.
Intra-articular Topical
Non-pharmacological Therapy
steriods/hyaluronate
Surgery
analgesics/NSAIDs
Non-pharmacological options include exercise, body mass index
Narcotic
(BMI), prevention of injury, misalignment (e.g. orthesis) and local
analgesics
measures (e.g. thermal modalities, transcutaneous electrical nerve
NSAIDs, including
stimulation [TENS], acupuncture). Among these treatment options,
COX-2-selective inhibitors
exercise may help by improving motion and strengthening muscles,
Acetaminophen,
weight loss could reduce disease progression, especially in
SySADOAs
overweight patients with knee or hip OA, while prevention of injury
Non-pharmacological therapy
may help to prevent the development of OA.
Patient education Telephone support
Weight loss Physical therapy
Systemic Pharmacological Therapy
Occupational therapy Aerobic exercise programmes
Systemic agents include acetaminophen/paracetamol, NSAIDs,
opioids and SySDOAs. The NSAIDs are associated with some adverse
COX = cyclo-oxygenase; NSAID = non-steroidal anti-inflammatory drug; effects, such as gastrointestinal (GI) toxicity. A strategy being
SySADOAs = symptomatic slow-acting drugs in osteoarthritis.
evaluated is to combine the NSAIDs, particularly the COX-2-selective
9
Adapted from Zhang et al., 2008 and the American College of Rheumatology
10
Subcommittee on Osteoarthritis Guidelines, 2000. inhibitors, with nitric oxide (NO) donors as NO could help maintain
normal blood pressure and hence make the NSAIDs safer to use.
Future Directions for the EULAR Among the SySDOAs, the most commonly used agents are CS,
Osteoarthritis Guidelines glucosamine (GLU), diacerin and avocado–soybean unsaponifiables
There is continent-wide consensus with the EULAR recommendations (ASUs). They have been proved effective in several clinical trials,
for the management of OA. Most evidence is available for treatment mainly for the management of OA of weight-bearing joints such as the
modalities in knee OA, while the evidence for the treatment of hip OA knee and hip.
5,6
CS and ASUs have also been shown to be effective for
is usually from studies comparing treatment of both the hip and the the management of hand OA.
7
knee. Hand OA seems to be a forgotten disease as there is very little
evidence available for its treatment. The recommendations are quite Locally Acting Pharmacological Therapy
strong and credible based on their scope, rigour of development and Locally acting therapies for the management of OA include topical
clarity. For instance, the methods used to synthesise research therapies and injectable agents.
evidence (systematic review) and expert opinion (Delphi approach)
are robust. These recommendations are considered particularly Topical therapies include the NSAIDs and capsaicin. Topical NSAIDs
strong due to their attempt to fill the gap between guidelines based are gaining popularity compared with systemic NSAIDs as topical
solely on either research evidence or expert opinion. In terms of the administration offers several advantages over the systemic agents.
future directions for the development of guidelines, there is a need to Topical agents can achieve efficacy with low systemic exposure and
update the EULAR recommendations for the management of knee therefore offer a lower potential for adverse effects.
11–14
They also
OA. The last guidelines were developed in 2003 and since then new allow a targeted method of treatment.
13,15
Topical agents offer an
scientific data have become available, such as the long-term alternative option for patients who do not want to take pills.
12
They
structure- and symptom-modifying effect of CS.
4,8
n may also be beneficial for patients taking multiple medications as the
topical agents have a lower potential for drug–drug interactions and
Comprehensive Strategies for the their use would also reduce the pill burden.
12
In clinical trials, topical
Treatment of Osteoarthritis Targeting NSAIDs have demonstrated similar efficacy to oral NSAIDs for the
Both Symptoms and Structural Changes treatment of OA pain.
16–18
Among the currently available NSAIDs for
topical use, a new salt of diclofenac (diclofenac epolamine) with
a report on a presentation by enhanced hydro- and lipo-solubility has been developed by IBSA
Jean-Pierre Pelletier Institut Biochimique SA (Lugano, Switzerland) in the form of gel and
patch formulations.
19
Osteoarthritis Research Unit, University of Montréal
Injectable formulations have been used for several years in the
The ultimate goal of therapeutic intervention in OA is to improve treatment of OA and include intra-articular corticosteroids and intra-
disease symptoms, patient function and quality of life, and to retard or articular hyaluronic acid (HA). Intra-articular administration of
even stop disease progression. Additionally, the drugs used need to corticosteroids is used mainly for fast-acting anti-inflammatory
have a good safety profile as patients are usually old and have to take effects. A literature review by the Cochrane group has evaluated the
the medications for a long period. The classic therapeutic strategy is use of intra-articular corticosteroids in the treatment of knee OA.
20
based on a pyramidal approach where patients are initially treated This review concluded that the corticosteroids were effective in
with non-pharmacological therapies (see Figure 1).
9,10
If signs and reducing the signs of acute inflammation, and that the treatment is an
symptoms of disease are not controlled, pharmacological therapy is effective short-acting measure to relieve pain and symptoms,
considered, while surgery may be an option in cases of severe pain. particularly effusion. Contrary to fears that the frequent use of
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