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This article reviews the differences
between the latest domestic and foreign osteoarthritis treatment guidelines.
mobility in the affected joint.
Other common symptoms include joint swelling, bone abrasion, joint strangulation, muscle weakness and poor balance, and joint deformities
may occur in advanced stages.
The prevalence of OA is increasing worldwide, especially in women, people living in poor areas, people aged 45 years and older, and people who are obese
.
OA has a significant negative impact
on patients' daily activities, quality of life, and health.
On October 19, 2022, the UK's National Health and Care Optimization Study (NICE) released the latest Guidelines for the Diagnosis and Management of Osteoarthritis[1] (hereinafter referred to as the "NICE Guidelines"), and in the same month, the Rheumatology Branch of the Chinese Medical Association also released the latest guidelines for the diagnosis and treatment of osteoarthritis in 2022 [2] (hereinafter referred to as the "China Guidelines"), this article focuses on the comparative interpretation of
the differences between the two in diagnosis, evaluation and treatment.
NICE Osteoarthritis Guidelines for Diagnosis
▌NICE Guidelines
:
1.
The following groups can be clinically diagnosed without imaging examination:
•45 years old or older;
•with activity-related joint pain;
• Not accompanied by joint stiffness or morning stiffness lasting no more than 30 minutes
.
2.
It is not recommended to routinely use imaging to diagnose OA, unless there are atypical features, such as recent trauma history, prolonged joint stiffness, rapid deterioration of joint symptoms or deformities, redness, swelling and pain in local joints, suggesting possible infection or malignant tumors and other diagnoses
.
Chinese guidelines: The diagnosis of OA is generally based on symptoms such as pain during joint movement, transient morning stiffness and joint dysfunction, signs such as bone abrasion, joint tenderness, bony hypertrophy, and X-ray examination, and no specific laboratory tests to exclude other inflammatory arthritis
.
Comments:
NICE guidelines emphasize that OA is diagnosed clinically and usually does not require imaging to confirm the diagnosis
.
Chinese guidelines consider x-rays of the affected area not necessary in patients with typical symptoms, but are still important
for the diagnosis of OA.
Assessment
▌NICE guidelines:
OA management should be guided by symptoms and physical function, exercise therapy and weight management are the core treatment options, Adjust according to the different needs of patients and participate in decision-making plans
.
Chinese guidelines: Evaluation of OA should include OA predisposing factors, pain profile, concomitant conditions, and risk of treatment, with a complete history and detailed physical examination to determine the patient's knowledge of OA, participation in previous treatments, and expectations and preferences
for treatment.
Comments:
Both guidelines emphasize the development of individualized treatment strategies
based on the results of the overall assessment.
Non-drug treatment
1, exercise therapy
▌NICE guidelines:
Research evidence shows that exercise has significant benefits for people with OA, as well as a high
safety profile compared to other common treatments such as analgesia.
The expert group particularly emphasized the importance of physical exercise, which is the core treatment plan
.
Exercise can help patients control and reduce symptoms and improve physical function
.
1.
1 For all patients with OA, a personalized exercise treatment plan is usually developed according to the specific performance of the patient, and therapeutic exercise is provided for them (such as increasing local muscle strength, aerobic exercise is generally recommended);
1.
2 Consider supervised exercise for patients with OA;
1.
3 Inform OA patients that exercise therapy may increase joint pain, but regular and consistent appropriate exercise can improve joint function and quality of life
.
Chinese guidelines: Patients with OA should use exercise as the core treatment regimen
regardless of age, complications, pain severity, or degree of functional impairment.
Exercise can enhance muscle strength and better protect joints; Cartilage has no blood supply, and it is necessary to obtain nutrition from joint fluid through exercise and squeezing, and people who do not exercise for a long time are more prone to degeneration of joint cartilage; Exercise is beneficial
to organs throughout the body such as the heart, brain, lungs, etc.
Comments:
Both guidelines agree that the core position of exercise in OA treatment is important, and enhancing motor function in OA patients is of great
significance to OA treatment.
2.
Weight management
▌NICE guidelines: For overweight or obese patients with OA:
Studies have shown that the percentage of weight change has a dose-effect relationship
with the improvement of joint symptoms.
2.
1 Weight loss is recommended, weight loss can improve the quality of life and physical function of patients with OA, and reduce pain;
2.
2 It is recommended to set a weight loss goal;
2.
3 Any degree of weight loss is beneficial, and symptom improvement is more pronounced
when weight loss is more than 10%.
Chinese guidelines: Weight management is the core treatment option
for hip OA and knee OA.
During weight-bearing activities, the hip and knee joints are subjected to a large load
.
Weight loss methods in obese patients recommend dietary calorie restriction combined with exercise
.
Older people should do strength training
at the same time.
Comments:
Both guidelines agree that weight management and exercise are the cornerstones of OA treatment, and maintaining an ideal weight is important
to protect joint structure and improve symptoms.
3.
Manual therapy ▌NICE guidelines:
only manual therapy (such as tuina, manipulation or soft tissue techniques):
3.
1 Patients with hip OA or knee OA;
3.
2 Manual therapy at the same time as exercise has some clinical benefit for hip OA and knee OA, but may not be effective for other joints
。 There is currently insufficient evidence to support manual therapy alone for the treatment of OA
.
If manual therapy is used, it needs to be combined with exercise therapy, and the patient may benefit more
.
4.
Acupuncture ▌NICE Guidelines:
Based on limited research evidence and economic cost considerations, acupuncture or dry acupuncture
is currently not recommended for the treatment of OA
。
5.
Radiotherapy ▌NICE guidelines:
Most of the results of radiotherapy
studies show little benefit to patients with OA.
The following electrotherapy methods are not recommended for the treatment of OA:
• Transcutaneous electrical nerve stimulation (TENS); • Ultrasound therapy; • interference therapy; • Laser treatment; • pulsed shortwave therapy; • Neuromuscular electrical stimulation (NMES).
Chinese guidelines: Physical therapy mainly reduces joint pain by promoting local blood circulation and reducing inflammation
.
Common methods include hydrotherapy, cold therapy, heat therapy, massage, acupuncture, pulsed ultrasound therapy, and interfering electrical stimulation therapy, which may be effective
.
Comments:
NICE guidelines recommend that patients with hip OA and knee OA treated by manual methods should be combined with exercise and exercise, and acupuncture and electrotherapy are not recommended; Chinese guidelines suggest that physical therapy may be effective
.
6.
Walking aids ▌NICE guidelines:
6.
1 Consider providing walking aids
(such as walking sticks) for patients with lower limb OA;
6.
2 Insoles, braces, tapes, splints or supports are not recommended for patients with OA unless there is joint instability or abnormal biomechanical load; the absence of aids that make exercise therapy ineffective or unsuitable; Adding assistive tools may improve patient movement and function
.
Chinese guidelines: Patients should choose appropriate mobility aids such as canes, crutches, walkers, joint braces, etc.
under the guidance of a doctor
when necessary.
Splinting is recommended for OA at the base of the thumb and choosing flat, thick, soft, loose footwear to aid walking
.
Patients with lateral tibinofemoral OA with knee valgus can use a medial wedge insole to improve pain
.
Comments:
Compared with Chinese guidelines, NICE guidelines recommend that in addition to lower limb OA patients to provide walking aids, other OA patients do not recommend the use of assistive tools
when necessary.
Drug treatment
1.
Topical, oral and transdermal drugs
▌NICE guidelines:
Nonsteroidal anti-inflammatory drugs (NSAIDs) have both analgesic and anti-inflammatory effects and are the most commonly used class of drugs
to control OA symptoms.
Topical NSAIDs have less systemic absorption and few
side effects.
1.
1 OA requiring drug treatment should pay attention to the following points:
• Simultaneous with non-drug treatment and physical exercise
.
• Treatment
in the shortest possible time and at the lowest effective dose.
1.
2 Patients with knee OA are provided with local NSAIDs;
1.
3 For patients with OA with other joints, topical NSAIDs can be considered;
1.
4 If topical agents are ineffective or inappropriate, oral NSAIDs may be considered, taking into account potential gastrointestinal, renal, hepatic and cardiovascular toxicity, age, pregnancy, current pharmacotherapy and complications
.
Provide gastric protective therapy such as proton pump inhibitors to patients with OA while they are taking NSAIDs;
1.
5 Routine use of paracetamol (acetaminophen) or weak opioids is not recommended, except occasionally for short-term analgesia and contraindications, intolerance or ineffectiveness of all other drug treatments;
1.
6 The use of glucosamine or potent opioids is not recommended, and there is currently insufficient evidence that glucosamine is beneficial
for people with OA.
The risks of potent opioids outweigh the benefits
.
Chinese guidelines: NSAIDs are the first-line drug
for OA medication.
Patients who do not respond to resolution with topical agents may be given NSAIDs
by mouth.
The lowest effective dose should be used, a short course of treatment should be used, and the choice of drug type and dose should be individualized
.
Note the main adverse reactions of NSAIDs, patients with high gastrointestinal risk should choose COX-2 selective inhibitors as much as possible, and use NSAIDs
with caution if there is a high risk of cardiovascular disease and/or renal insufficiency.
Commonly used drugs in clinical practice, such as glucosamine sulfate, chondroitin sulfate, diacetorein and intra-articular injection of hyaluronic acid, etc.
, evidence-based medical evidence is inconsistent and may have a certain effect
.
Comments:
There are currently no recognized drugs that prevent the progression of
OA.
Both guidelines recommend NSAIDs as the first-line drug for OA drug treatment, and patients who cannot be relieved by external drugs can be taken orally, emphasizing the lowest effective dose, short-course treatment, and individualized treatment
for drug type and dose selection, adverse reactions, etc.
2.
Joint injection of drugs
▌NICE guidelines:
2.
1 It is not recommended to inject sodium hyaluronate intra-articular for the treatment of OA
.
Whether hyaluronic acid injection into the joint cavity improves quality of life or physical function in patients with knee OA or hip OA, the results of current research are inconsistent and unclear;
2.
2 When other drug treatments are ineffective or contraindicated, intra-articular corticosteroid injection for OA can be considered to relieve pain
Chinese guidelines: For patients with severe OA with acute onset of severe pain, nocturnal pain, and joint effusion, intra-articular injection of corticosteroids can quickly relieve pain, and the effect lasts for weeks to months, and long-term multiple applications have the risk of accelerating joint cartilage loss, so the same joint should not be injected repeatedly, and the interval between injections should not be shorter than 3 months
.
Comments:
Both guidelines recommend intra-articular corticosteroid injections for short-term pain
relief in patients with OA.
Imaging therapy
for OA ▌NICE guidelines:
not recommended Use imaging to follow up or guide non-surgical treatment of
OA.
OA can be diagnosed by a thorough history and examination, and the available evidence suggests that imaging studies are of little value in the diagnosis of OA and do not respond to treatment
.
Imaging is more
valuable when patients present with atypical features or when other inflammatory arthritis (e.
g.
, rheumatoid arthritis) and malignancy are considered.
Chinese guidelines: X-rays of the affected area are not necessary in patients with typical symptoms, but remain important
for the diagnosis of OA.
Joint ultrasound can identify cartilage destruction, synovitis, joint effusion, and osteophytes
.
Most patients with typical symptoms of OA do not require joint MRI
.
However, MRI is the only imaging method that can directly show articular cartilage, which is of great significance
for the diagnosis of OA in the early stage.
Comments:
Compared with NICE guidelines, Chinese guidelines emphasize the status
of imaging in OA diagnosis and treatment.
Surgical treatment
1, joint replacement
▌NICE guidelines:
1.
1 Joint replacement is considered in patients with hip, knee, or shoulder OA when they have:
•Joint symptoms (eg, pain, stiffness, decreased function, or progressive joint deformity) seriously affect the quality of life of
patients with OA.
•Nonsurgical treatments (eg, exercise therapy, weight loss, pain relief) are ineffective or inappropriate
.
1.
2 It is recommended that patients undergo joint replacement using clinical assessments rather than digital scores of disease severity, such as knee injury and osteoarthritis scores (KOOS) and hip disability and osteoarthritis scores (HOOS).
China Guidelines: The prerequisites for obtaining good results of joint replacement are to correctly grasp the indications for artificial joint replacement, choose the most appropriate timing, use the most suitable artificial joint, have rich experience in the operator, and obtain the trust and cooperation
of patients and families.
Comments:
Compared with NICE guidelines, Chinese guidelines need to consider many factors
for the conditions of joint replacement surgery for patients with OA.
2.
Arthroscopic surgery
▌NICE guidelines:
Joint lavage or debridement is not recommended for patients with OA
.
There is insufficient evidence to show that arthroscopic surgery reduces pain and improves physical function
.
In addition, arthroscopic surgery may have other risks, the cost is higher, and arthroscopic surgery is more expensive
than standard care.
Chinese guidelines: Procedures not recommended include articular lavage, arthroscopic joint cleanup, abrasive arthroplasty, and synovectomy
.
Comments:
In terms of the validity and safety of medical evidence and economic costs, neither guideline recommends arthroscopic surgery and related procedures
for patients with OA.
References:
[1] Osteoarthritis in over 16s:diagnosis and management.
NICE guideline[NG226]Published:19 October 2022.
[2] Zhao Yanping,Lin Zhiguo,Lin Shudian,Xia Liping,Zhang Zhiyi,Zhao Yan.
Diagnosis and treatment of osteoarthritis[J].
Chinese Journal of Internal Medicine,2022,61(10):1136-1143.
)
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