Medical management of adults with osteoarthritis.
BIBLIOGRAPHIC SOURCE(S)
Michigan Quality Improvement Consortium. Medical management of adults with osteoarthritis. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Aug. 1 p.
GUIDELINE STATUS
This is the current release of the guideline.
This guideline updates a previous version: Michigan Quality Improvement Consortium. Medical management of adults with osteoarthritis. Southfield (MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.
** REGULATORY ALERT **
FDA WARNING/REGULATORY ALERT
Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.
January 16, 2009 - Topical Anesthetics: The U.S. Food and Drug Administration (FDA) issued a public health advisory to remind patients, healthcare professionals, and caregivers about potentially serious hazards of using skin numbing products, also known as topical anesthetics, for relieving pain from mammography and other medical tests and conditions. FDA is concerned about the potential for these products to cause serious, life-threatening adverse effects, such as irregular heartbeat, seizures, breathing difficulties, coma and even death, when applied to a large area of skin or when the area of application is covered. See the Advisory for recommendations on safe use of these products.
MAJOR RECOMMENDATIONS
The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.
Initial Evaluation
Detailed history (aspirin use, pain control with over-the-counter medications, activity tolerance and limitations)
Physical examination
Assess gastrointestinal (GI) risk:
History of GI bleeding
History of peptic ulcer disease and/or non-steroidal induced GI symptoms
Concomitant use of corticosteroids and/or warfarin [A]
High dose, chronic, or multiple non-steroidal anti-inflammatory drugs (NSAIDs) including aspirin
Age >60 years
Nonpharmacologic Modalities
Treatment plan should include:
Education and counseling regarding weight reduction and joint protection
Range-of-motion [B], aerobic, and muscle strengthening exercises
For patients with functional limitations, consider physical and occupational therapy
Self-management resources (e.g., American Arthritis Foundation self help course and book
For select patients:
Assistive devices for ambulation and activities of daily living
Appropriate footwear, orthotics (e.g., wedged insoles)
Pharmacologic Therapy
Therapies Other than NSAIDs
Initial drug of choice: acetaminophen 4 g/day, modify dose for patients at risk for toxicity (note patients with hepatic toxicity risk factors, especially those on aspirin). Reassess and taper as tolerated.
Topical capsaicin
NSAID Analgesics
No Cardiovascular Risk
No or low NSAID GI risk
NSAID
Add a proton pump inhibitor (PPI)1 if on aspirin, plus risk warrants GI protection
NSAID GI risk
NSAID plus PPI1
If NSAID not tolerated, cyclo-oxygenase-2 (COX-2) selective inhibitor
For those with prior GI bleed avoid all NSAIDs/COX-2, if must use, then COX-2 plus PPI1 [D]
Cardiovascular Risk
No or low NSAID GI risk
Naproxen2,3
Add PPI1 if GI risk of aspirin/NSAID combination warrants GI protection
NSAID GI risk
Naproxen2,3 plus PPI1 if cardiovascular risk > GI risk
COX-2 plus PPI1 if GI risk > cardiovascular risk
1Misoprostol at full dose (200 micrograms four times a day) may be substituted for PPI.
2Naproxen probably has lowest cardiovascular risk of NSAID/COX-2 class.
3If aspirin is used daily, COX-2 offers no advantage over NSAID.
Other Pharmacologic Agents
Nonacetylated salicylate, tramadol, opioids, intra-articular glucocorticoids or hyaluronate, lidoderm or methylsalicylate
Definitions:
Levels of Evidence for the Most Significant Recommendations
Randomized controlled trials
Controlled trials, no randomization
Observational studies
Opinion of expert panel
