Treatment options for patients with advanced osteoarthritis who decline knee surgery

Table 1 International guidelines comparison for non-surgical knee osteoarthritis treatment

Domain	EULAR/ESCEO	ACR	OARSI	AAOS	NICE
Exercise	+++	+++	+++	+++	+++
Weight management	+++	+++	+++	++	+++
Topical NSAIDs	+++	+++	+++	+++	+++
Oral NSAIDs	+++	+++	++	+++	++
Acetaminophen	+	++	-	+++	+
Intra-articular corticosteroids	+	+++	++	++	++
Intra-articular hyaluronic acid	+	-	++	-	-
Opioids1	+	++	--	--	+
Duloxetine	+	++	+	ND	ND
Supplementation	++	--	-	+	--
Bracing	+	++	-	+	+

¹Among opioids guidelines often make a distinction between tramadol and other opioids. If this distinction is made the recommendation for tramadol is applied.

+++: Strong recommendation; ++: Conditional recommendation; +: Weak recommendation, -: Conditional recommendation against; --: Strongly recommended against; ND: Not defined; EULAR: European Alliance of Associations for Rheumatology; ESCEO: Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases; ACR: American College of Rheumatology; OARSI: Osteoarthritis Research Society International; AAOS: American Academy of Orthopedic Surgeons; NICE: United Kingdom’s National Institute for Health and Care Excellence; NSAID: Non-steroidal anti-inflammatory drugs.

Table 2 Most important differences and take-away points from clinical guidelines

Domain	Key points or differences: EULAR/ESCEO, ACR, OARSI, AAOS, NICE
Exercise	Optimal exercise protocols have not been identified; hence, exercise should be tailored to a patient’s needs and accessibility. ACR and OARSI endorse Tai Chi/Yoga
Weight management	Weight loss for overweight or obese patients is generally strongly recommended
Topical NSAIDs	The use of topical NSAIDs is a core recommendation
Oral NSAIDs	Generally, a strong recommendation but some point to the fact that they should be used after topical
Acetaminophen	OARSI discourages acetaminophen while AAOS has the best outlook. Other guidelines suggest its use during flare ups
Intra-articular corticosteroids	Guidelines recommend intra-articular corticosteroids for short-term relief, but repeated use is discouraged
Intra-articular hyaluronic acid	OARSI has the best outlook on HA, suggesting HA may have longer lasting effects and a good safety profile. ESCEO points to use when patients have contraindications to NSAIDs. ACR, AAOS, and NICE recommend clinicians against frequent use
Opioids	AAOS and OARSI strongly discourage opioids due to risks. Otherwise, tramadol could be used conditionally, for example, in severe cases
Duloxetine	Duloxetine could be used to help patients with widespread pain and as an alternative to opioids, but AAOS and NICE have not made a recommendation
Supplementation	If recommended its use is rather limited to early cases
Bracing	Insoles are generally not recommended but braces and walking aids may be recommended with emphasis on increasing participation in physical activity. OARSI recommends against bracing of the knee but conditionally recommends walking aids

EULAR: European Alliance of Associations for Rheumatology; ESCEO: Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases; ACR: American College of Rheumatology; OARSI: Osteoarthritis Research Society International; AAOS: American Academy of Orthopedic Surgeons; NICE: United Kingdom’s National Institute for Health and Care Excellence; NSAID: Non-steroidal anti-inflammatory drugs; HA: Hyaluronic acid.