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Guideline Summary
Guideline Title
Medical management of adults with osteoarthritis.
Bibliographic Source(s)
Michigan Quality Improvement Consortium. Medical management of adults with osteoarthritis. Southfield (MI): Michigan Quality Improvement Consortium; 2011 Aug. 1 p.
Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • August 1, 2013 – Acetaminophen External Web Site Policy: The U.S. Food and Drug Administration (FDA) notified healthcare professionals and patients that acetaminophen has been associated with a risk of rare but serious skin reactions. Acetaminophen is a common active ingredient to treat pain and reduce fever; it is included in many prescription and over-the-counter (OTC) products. These skin reactions, known as Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP), can be fatal. These reactions can occur with first-time use of acetaminophen or at any time while it is being taken. Other drugs used to treat fever and pain/body aches (e.g., non-steroidal anti-inflammatory drugs, or NSAIDS, such as ibuprofen and naproxen) also carry the risk of causing serious skin reactions, which is already described in the warnings section of their drug labels.

Scope

Disease/Condition(s)

Osteoarthritis

Guideline Category
Evaluation
Management
Risk Assessment
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Neurology
Rheumatology
Intended Users
Advanced Practice Nurses
Health Plans
Physician Assistants
Physicians
Guideline Objective(s)
  • To achieve significant, measurable improvements in the management of osteoarthritis through the development and implementation of common evidence-based clinical practice guidelines
  • To design concise guidelines that are focused on key management components of osteoarthritis to improve outcomes
Target Population

Adults with clinical suspicion or confirmed diagnosis of osteoarthritis

Interventions and Practices Considered

Evaluation

Detailed history, physical examination, and assessment of gastrointestinal (GI) risk

Management/Treatment

Non-Pharmacologic Modalities

  1. Education and counseling
  2. Range-of-motion, aerobic, and muscle strengthening exercises
  3. Physical therapy and occupational therapy
  4. Self-management
  5. Assistive devices

Pharmacologic Therapy

  1. Acetaminophen
  2. Topical capsaicin
  3. Non-steroidal anti-inflammatory drugs (NSAIDs)
  4. Cyclo-oxygenase-2 (COX-2) selective inhibitors
  5. Other pharmacologic agents
Major Outcomes Considered

Not stated

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The Michigan Quality Improvement Consortium (MQIC) health care analyst conducts a search of current literature in support of the guideline topic. Computer database searches are used to identify published studies, existing protocols and/or national guidelines on the selected topic developed by organizations such as the American Diabetes Association, American Heart Association, American Academy of Pediatrics, etc. If available, clinical practice guidelines from participating MQIC health plans and Michigan health systems are also used to develop a framework for the new guideline.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational studies
  4. Opinion of expert panel
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Using information obtained from literature searches and available health plan guidelines on the designated topic, the Michigan Quality Improvement Consortium (MQIC) health care analyst prepares a draft guideline to be reviewed by the medical directors' committee at one of their scheduled meetings. Priority is given to recommendations with [A] and [B] levels of evidence (see the "Rating Scheme for the Strength of the Evidence" field).

The initial draft guideline is reviewed, evaluated, and revised by the committee resulting in draft two of the guideline. Additionally, the Michigan Academy of Family Physicians participates in guideline development at the onset of the process and throughout the guideline development procedure. The MQIC guideline feedback form and draft two of the guideline are distributed to the medical directors, as well as the MQIC measurement and implementation group members, for review and comments.  Feedback from members is collected by the MQIC health care analyst and prepared for review by the medical directors' committee at their next scheduled meeting. The review, evaluation, and revision process with several iterations of the guideline may be repeated over several meetings before consensus is reached on a final draft guideline.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

When consensus is reached on the final draft guideline, the medical directors approve the guideline for external distribution to practitioners with review and comments requested via the Michigan Quality Improvement Consortium (MQIC) health plans (health care analyst distributes final draft to medical directors' committee, measurement and implementation groups to solicit feedback).

The MQIC health care analyst also forwards the approved guideline draft to appropriate state medical specialty societies and physicians with expertise in the related field for their input. After all feedback is received from external reviews, it is presented for discussion at the next scheduled committee meeting. Based on feedback, subsequent guideline review, evaluation, and revision may be required prior to final guideline approval.

The MQIC Medical Directors approved this updated guideline in August 2011.

Recommendations

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Initial Evaluation

  • Detailed history (aspirin use, pain control with over-the-counter medications, activity tolerance and limitations)
  • Physical examination
  • Assess gastrointestinal (GI) risk:
    • History of GI bleeding
    • History of peptic ulcer disease and/or non-steroidal induced GI symptoms
    • Concomitant use of corticosteroids and/or warfarin [A]
    • High dose, chronic, or multiple non-steroidal anti-inflammatory drugs (NSAIDs) including aspirin
    • Age >60 years

Nonpharmacologic Modalities

Multi-faceted treatment plan should include:

  • Education and counseling regarding weight reduction and joint protection
  • Range-of-motion [B], aerobic, and muscle strengthening exercises
  • For patients with functional limitations, consider physical and occupational therapy
  • Self-management resources (e.g., American Arthritis Foundation self-help course and book, arthritis.org/programs.php External Web Site Policy)

For select patients:

  • Assistive devices for ambulation and activities of daily living

Pharmacologic Therapy

Therapies Other than NSAIDs

  • Initial drug of choice: Acetaminophen at minimum effective dose, lower dose for patients with risk factors for toxicity (hepatic toxicity risk factors, aspirin, warfarin). Warn patients that many over the counter products contain acetaminophen and to monitor dose carefully. Reassess and taper as tolerated.
  • Topical capsaicin

NSAID Analgesics

NSAID and Analgesics GI Risk

  • NSAID
  • Add a proton pump inhibitor (PPI)1 if on aspirin, or if risk warrants GI protection

NSAID GI Risk

  • NSAID plus proton pump inhibitor (PPI)1
  • If NSAID not tolerated, cyclo-oxygenase-2 (COX-2) selective inhibitor
  • For those with prior GI bleed avoid all NSAIDs/COX-2; if must use, then COX-2 plus PPI1 [D]

Use with caution in patients with hypertension (HTN) and stable cardiovascular (CV) disorders only when the individual clinical benefit outweighs the cardiovascular risk2,3

1Misoprostol at full dose (200 µg four times a day) may be substituted for PPI.
2Naproxen may have lowest cardiovascular risk of NSAID/COX-2 class.
3If aspirin is used daily, COX-2 offers no advantage over NSAID.

Other Pharmacologic Agents

Nonacetylated salicylate, tramadol, opioids, intra-articular glucocorticoids or hyaluronate, topical lidocaine or methyl salicylate

Definitions:

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational studies
  4. Opinion of expert panel
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence is provided for the most significant recommendations (See "Major Recommendations" field).

The guideline is based on the following sources: The 2000 American College of Rheumatology Subcommittee on Osteoarthritis Guidelines: Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee (www.rheumatology.org External Web Site Policy); American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the Knee (non-Arthroplasty). December 6, 2008; and, Scheiman JM. Summing the Risk of NSAID Therapy. Lancet 2007; 369:1580-1.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Through a collaborative approach to developing and implementing common clinical practice guidelines and performance measures for osteoarthritis, Michigan health plans will achieve consistent delivery of evidence-based services and better health outcomes. This approach also will augment the practice environment for physicians by reducing the administrative burdens imposed by compliance with diverse health plan guidelines and associated requirements.

Potential Harms
  • For patients with prior gastrointestinal (GI) bleed, avoid all non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (COX-2) selective inhibitors. If must use, then COX-2 plus proton pump inhibitor (PPI) should be used. NSAIDs should be used with caution in patients with hypertension and stable cardiovascular disorders only when the individual clinical benefit outweighs the cardiovascular risk.
  • Acetaminophen dose should be lower for patients with risk factors for toxicity (hepatic toxicity risk factors, aspirin, warfarin). Warn patients that many over-the-counter products contain acetaminophen and to monitor dose carefully.

Qualifying Statements

Qualifying Statements

This guideline lists core management steps. Individual patient considerations and advances in medical science may supersede or modify these recommendations.

Implementation of the Guideline

Description of Implementation Strategy

Approved Michigan Quality Improvement Consortium (MQIC) guidelines are disseminated through email, U.S. mail, and websites.

The MQIC health care analyst prepares approved guidelines for distribution. Portable Document Format (PDF) versions of the guidelines are used for distribution.

The MQIC health care analyst distributes approved guidelines to MQIC membership via email.

The MQIC health care analyst submits request to website vendor to post approved guidelines to MQIC website (www.mqic.org External Web Site Policy).

The MQIC health care analyst completes an annual statewide postcard mailing to physicians in all areas of medicine including primary care and specialties. The postcard provides the complete list of MQIC guidelines and includes which guidelines have been recently revised, which are coming up for revision, and any new published guidelines.

The statewide mailing list is derived from the Blue Cross Blue Shield of Michigan (BCBSM) provider database. Approximately 95% of the state's M.D.'s and 96% of the state's D.O.'s are included in the database.

The MQIC health care analyst submits request to the National Guidelines Clearinghouse (NGC) to post approved guidelines to NGC website (www.guideline.gov External Web Site Policy).

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Michigan Quality Improvement Consortium. Medical management of adults with osteoarthritis. Southfield (MI): Michigan Quality Improvement Consortium; 2011 Aug. 1 p.
Adaptation

The guideline is based on the following sources: The 2000 American College of Rheumatology Subcommittee on Osteoarthritis Guidelines: Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee (www.rheumatology.org External Web Site Policy); American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the Knee (non-Arthroplasty). December 6, 2008; and Scheiman JM. Summing the Risk of NSAID Therapy. Lancet 2007; 369:1580-1.

Date Released
2003 Aug (revised 2011 Aug)
Guideline Developer(s)
Michigan Quality Improvement Consortium - Professional Association
Source(s) of Funding

Michigan Quality Improvement Consortium

Guideline Committee

Michigan Quality Improvement Consortium Medical Directors Committee

Composition of Group That Authored the Guideline

Physician representatives from the 13 participating Michigan Quality Improvement Consortium health plans, Michigan State Medical Society, Michigan Osteopathic Association, Michigan Association of Health Plans, Michigan Department of Community Health, Michigan Peer Review Organization, and the University of Michigan Health System

Financial Disclosures/Conflicts of Interest

Standard disclosure is requested from all individuals participating in the Michigan Quality Improvement Consortium (MQIC) guideline development process, including those parties who are solicited for guideline feedback (e.g., health plans, medical specialty societies). Additionally, members of the MQIC Medical Directors' Committee are asked to disclose all commercial relationships as well.

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available in Portable Document Format (PDF) from the Michigan Quality Improvement Consortium Web site External Web Site Policy.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on April 14, 2004. The information was verified by the guideline developer on July 27, 2004. This summary was updated by ECRI on January 12, 2005 following the release of a public health advisory from the U.S. Food and Drug Administration regarding the use of some non-steroidal anti-inflammatory drug products. This summary was updated on April 15, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective non-steroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This NGC summary was updated by ECRI on November 28, 2005. The updated information was verified by the guideline developer on December 19, 2005. This NGC summary was updated by ECRI Institute on March 4, 2008. The updated information was verified by the guideline developer on March 12, 2008. This summary was updated by ECRI Institute on March 10, 2009, following the U.S. Food and Drug Administration advisory on Topical Anesthetics. This NGC summary was updated most recently by ECRI Institute on February 16, 2010. The updated information was verified by the guideline developer on March 22, 2010. This summary was updated by ECRI Institute on July 20, 2010 following the U.S. Food and Drug Administration advisory on Ultram (tramadol hydrochloride), Ultracet (tramadol hydrochloride/acetaminophen). This summary was updated by ECRI Institute on July 26, 2010 following the U.S. Food and Drug Administration (FDA) advisory on Proton Pump Inhibitors (PPI). This NGC summary was updated by ECRI Institute on May 29, 2012. The updated information was verified by the guideline developer on June 25, 2012. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen.

Copyright Statement

This NGC summary is based on the original guideline, which may be reproduced with the citation developed by the Michigan Quality Improvement Consortium.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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