Objective To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. Methods We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. Results Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. Conclusion This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

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2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee

https://archive-ouverte.unige.ch/unige:135623/ATTACHMENT01

An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

Optimal management of knee osteoarthritis (KOA) should include, where possible, modification of risk factors through targeted interventions. The objectives of the present narrative review were to identify, summarize, and cluster all the potentially modifiable risk factors that influence the course of KOA, and discuss their susceptibility to alteration via personal, clinical, and public strategy. For this purpose, Pubmed and Scopus databases were queried using the terms "knee osteoarthritis", "risk factors" and "improvement". Six main categories of modifiable risk factors were identified: (1) obesity and overweight, (2) comorbidity, (3) occupational factors, (4) physical activity, (5) biomechanical factors, (6) dietary exposures. In the era of age- and obesity-related diseases, the combined effects of local and systemic risk factors should be managed by combined measures. Femoral muscle-strengthening physical activities, complemented with proper diet, weight loss, vocational rehabilitation, management of comorbidities (especially diabetes and depression), and biomechanical support may add up to the holistic therapeutic approach towards the patient with KOA. An individual risk factor modification program should be developed in accordance with patient preferences and habits, workplace, medical history, and overall health condition. Due to its great impact on a wide range of functions and tissues, interventions on modifiable risk factors improve not only the symptoms of KOA but also affect the osteoarthritic joint as a whole.

Modifiable risk factors in knee osteoarthritis: treatment implications

High body mass index (BMI) is known to be associated with various conditions, including type 2 diabetes (T2D), osteoarthritis, cardiovascular disease (CVD) and sleep apnoea; however, the impact of intentional weight loss on the risk of these and other outcomes is not well quantified. We examined the effect of weight loss on ten selected outcomes in a population from the UK Clinical Practice Research Datalink (CPRD) GOLD database. Included individuals were >18 years old at the index date (first BMI value between January 2001 and December 2010). They were categorised by their weight pattern between year 1 post-index and year 4 post-index (baseline period) as having stable weight (-5% to +5%) or weight loss (-25% to -10%, plus evidence of intervention or dietary advice to confirm intention to lose weight). For inclusion, individuals also required a BMI of 25.0-50.0 kg/m2 at the start of the follow-up period, during which the occurrence of ten obesity-related outcomes was recorded. Cox proportional hazard models adjusted for BMI, comorbidities, age, sex and smoking status were used to estimate relative risks for weight loss compared with stable weight. Individuals in the weight-loss cohort had median 13% weight loss. Assuming a BMI of 40 kg/m2 before weight loss, this resulted in risk reductions for T2D (41%), sleep apnoea (40%), hypertension (22%), dyslipidaemia (19%) and asthma (18%). Furthermore, weight loss was associated with additional benefits, with lower risk of T2D, chronic kidney disease, hypertension and dyslipidaemia compared with maintaining the corresponding stable lower BMI throughout the study. This study provides objective, real-world quantification of the effects of weight loss on selected outcomes, with the greatest benefits observed for the established CVD risk factors T2D, hypertension and dyslipidaemia.

/pdf/weight-loss-and-risk-reduction-of-obesity-related-outcomes-116euq87am.pdf

Weight loss and risk reduction of obesity-related outcomes in 0.5 million people: evidence from a UK primary care database

Osteoarthritis (OA) is a complex musculoskeletal disease and a leading cause of pain and disability worldwide. Hip and knee OA alone are major contributors to global disability, having notable effects on individual well-being, increasing the reliance of individuals on health-care services and contributing to a rise in the socioeconomic burden. Consistent, coordinated and tailored approaches are important for providing appropriate care to all people with OA, but despite the scale of the challenge many individuals are still not offered the safe, best-evidence treatments recommended for OA care. This Review discusses the core priority treatments for OA, including exercise and physical activity, weight-loss, education and support for self-management. Additional physical or psychological evidence-based adjunctive therapies and combined therapies that can be used to tailor individual programmes are also discussed. These options include cognitive behavioural therapy, heat therapy, walking aids and splints, manual therapies and transcutaneous electrical nerve stimulation. International examples of OA treatment options, models of care and resources available are also given. Many challenges still need to be addressed to advance the uptake of these conditions, including further discussion around the risks and costs involved with all treatments. Various core and adjunctive therapies are available for osteoarthritis (OA) that can have beneficial effects on the well-being of the individual; however, challenges remain in implementing best-evidence, high-value care.

Core and adjunctive interventions for osteoarthritis: efficacy and models for implementation.

OBJECTIVE To determine the dose response effect of weight loss on clinical and mechanistic outcomes in overweight and obese adults with knee osteoarthritis (OA). METHODS This is a secondary analysis of the diet-induced weight loss only (D) and diet-induced weight loss plus exercise (D + E) groups in the Intensive Diet and Exercise for Arthritis randomized controlled clinical trial. The 240 participants were overweight and obese older community-dwelling adults with pain and radiographic knee OA. Participants were assigned to 1 of 4 groups according to weight loss achieved over an 18-month period: 20% (≥20% group). RESULTS There were significant dose responses to weight loss for pain (P = 0.01), function (P = 0.0006), 6-minute walk distance (P < 0.0001), physical (P = 0.0004) and mental (P = 0.03) health-related quality of life (HRQoL), knee joint compressive force (P < 0.0001), and interleukin-6 (P = 0.002). Greater weight loss resulted in superior clinical and mechanstic outcomes, with the highest weight loss group (≥20% group) distinguishing itself on all measures compared with the <5% and ≥5% groups; the ≥20% group had 25% less pain and better function compared with the ≥10% group and significantly (P = 0.006) better physical HRQoL. CONCLUSION Long-term weight loss of 10-19.9% of baseline body weight has substantial clinical and mechanistic benefits compared with less weight loss. The value of an additional 10% weight loss includes significantly improved physical HRQoL and a clinically important reduction of pain and improvement in function.

Allison E. Resnik

Papers

Intentional Weight Loss in Overweight and Obese Patients With Knee Osteoarthritis: Is More Better?