A practical approach to knee OA
This review of the latest evidence on existing and emerging treatment options can help to inform your decision-making process as you endeavor to provide patients with pain relief.
PRACTICE RECOMMENDATIONS
› Treat pain from knee osteoarthritis (OA) with weight management and low-impact exercise to decrease the risk of disease progression. A
› Prescribe oral or topical nonsteroidal anti-inflammatory drugs to relieve pain from knee OA, as both forms are equally effective. B
› Recommend a medial unloading (valgus) knee brace for short-term relief of medial knee OA. B
› Consider a trial of intra-articular corticosteroids or intra-articular hyaluronic acid derivatives for short-term relief of knee OA pain. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
HA is found naturally in articular cartilage, which explains the rationale behind its use. A network meta-analysis performed by the American Medical Society for Sports Medicine concluded that knee OA is more likely to respond to IAHA than to IACS or IA placebo, leading the society to recommend the use of IAHA in knee OA management, especially for patients > 60 years with mild-to-moderate knee OA.9 Conversely, the AAOS does not recommend the use of IAHA, and the ACR does not recommend for or against the use of IAHA.10,41
IACSs are commonly used to provide pain relief in those with moderate-to-severe knee OA. There is evidence that a single IACS injection provides mild pain relief for up to 6 weeks.49 However, there is some concern that repetitive IACS injections may speed cartilage loss. A 2-year randomized double-blind placebo-controlled trial comparing the effectiveness of repetitive IA triamcinolone vs saline in knee OA found no difference in pain severity and concluded that there was greater cartilage volume loss in the triamcinolone group.50
AAOS does not recommend for or against the use of IACSs, whereas the ACR does recommend for the use of IACSs.10,41 Given the available evidence, conservative use of IACS injections remains an option for patients with refractory moderate-to-severe knee OA.
Topicals
Topical analgesics are often utilized for knee OA because of their efficacy, tolerability, low risk of adverse effects, and ease of use. They are generally recommended over oral NSAIDs in the elderly and in individuals at risk for cardiac, renal, and gastrointestinal complications from oral NSAIDs.
One review found that topical diclofenac and topical ketoprofen were comparable to the oral forms of these medications.51 One RCT concluded that topical and oral diclofenac were equally efficacious in treating knee OA symptoms, although topical diclofenac was associated with significantly fewer gastrointestinal adverse effects.52 In multiple randomized trials, topical diclofenac has shown efficacy compared to placebo.53-55 A recent systematic review and meta-analysis of RCTs concluded that topical NSAIDs were safe and effective for treating general OA compared to placebo, with diclofenac patches most effective for pain relief and piroxicam most effective for functional improvement.56
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