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Guidelines 

Guidelines
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date: 29 May 2020

A number of treatment guidelines have been developed to optimize the treatment of osteoarthritis, some of which were recently updated. Fifty-one non-pharmacological, pharmacological, and surgical treatments are addressed in these guidelines but only two (oral opioid and intra-articular steroid injection) reach the minimal clinically important difference above placebo. Recommendations for these treatments vary depending on joint sites, risk:benefit ratio, and population. Exercise, self-management, and weight reduction if obese are universally recommended. While topical non-steroidal anti-inflammatory drugs (NSAIDs) remain a safe first-line drug option, the safety of paracetamol, the universally recommended first-line oral analgesic is increasingly questioned. Other analgesics such as oral NSAIDs (including selective cyclooxygenase 2 inhibitors), opioids, and antidepressants should be used according to patient characteristics and comorbidities. Nutraceuticals and complementary medicines remain controversial. While lavage is not recommended, total joint replacement is still considered as an effective treatment for the later stage of the disease irrespective of lack of placebo (sham) controlled trials. Stratified care has been attempted for recommendation according to joint affected and comorbidities but there is no evidence to support whether this can improve treatment outcomes. Guideline development groups differ in their composition and methodology. While the overall quality of guidelines has been improved, their applicability remains poor. Of the various factors that may influence implementation, suboptimal publishing and the efficacy paradox need to be recognized as important barriers.

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