• Michigan Quality Improvement Consortium. Medical management of adults with osteoarthritis. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Aug. 1 p.

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement Consortium. Medical management of adults with osteoarthritis. Southfield (MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

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

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

For select patients:

• Assistive devices for ambulation and activities of daily living
• Appropriate footwear, orthotics (e.g., wedged insoles)

Pharmacologic Therapy

Therapies Other than NSAIDs

• Initial drug of choice: acetaminophen 4 g/day, modify dose for patients at risk for toxicity (note patients with hepatic toxicity risk factors, especially those on aspirin). Reassess and taper as tolerated.
• Topical capsaicin

NSAID Analgesics

No Cardiovascular Risk

• No or low NSAID GI risk
  • NSAID
  • Add a proton pump inhibitor (PPI)¹ if on aspirin, plus risk warrants GI protection
• NSAID GI risk
  • NSAID plus PPI¹
  • 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]

Cardiovascular Risk

• No or low NSAID GI risk
  • Naproxen^2,3
  • Add PPI¹ if GI risk of aspirin/NSAID combination warrants GI protection
• NSAID GI risk
  • Naproxen^2,3 plus PPI¹ if cardiovascular risk > GI risk
  • COX-2 plus PPI¹ if GI risk > cardiovascular risk

¹Misoprostol at full dose (200 micrograms four times a day) may be substituted for PPI.

²Naproxen probably has 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, lidoderm or methylsalicylate

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

None provided

• Michigan Quality Improvement Consortium. Medical management of adults with osteoarthritis. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Aug. 1 p.

2003 Aug (revised 2007 Aug)

Michigan Quality Improvement Consortium - Professional Association

Michigan Quality Improvement Consortium

Michigan Quality Improvement Consortium Medical Director's Committee

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

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.

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement Consortium. Medical management of adults with osteoarthritis. Southfield (MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

None available

None available

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 nonsteroidal 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 most recently by ECRI Institute on March 4, 2008. The updated information was verified by the guideline developer on March 12, 2008.

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