Treatment Algorithm for Knee Osteoarthritis Patients

In 2014, the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) published a treatment algorithm for the management of knee osteoarthritis (OA). The algorithm provides practical guidance for the prioritization of interventions that may be offered by clinicians to patients suffering symptomatic OA. The guidelines “provide(s) an updated assessment of the literature for selected interventions in OA, focusing on real-life data". "Easy-to-follow advice on how to establish a treatment flow in patients with knee OA in primary care clinical practice" is provided, which in turn supports "the clinicians’ individualized assessment of the patient.” 

In short, the algorithm sequences initial pharmacological treatments, then moves on to either injectable corticosteroid or intra-articular hyaluronic acid (IA HA) which they claim “provides sustained clinical benefit with effects lasting up to 6 months after a short course of weekly injections”. A weak opioid follows as a last step before surgery. 

At a May 2015 review meeting and in their subsequently published paper the ESCEO task force stated: “Real-life evidence for the long-term effectiveness of IA HA is reported in a study of over 300 patients with knee OA who received repeat cycles of IA HA injections (4 cycles of 5 weekly injections).... After 40 months (12 months after the last treatment cycle), significantly more treatment responders were found in the treatment group compared with placebo according to OARSI 2004 criteria for pain, function, and patient global assessment (80.5% of responders with HA vs. 65.8% for placebo; p ¼ 0.004) [81]. Notably, the number of responders to IA HA increased progressively after each treatment cycle, while response to placebo remained fairly stable.” 

Similarly, in “other observational studies, IA HA injections in knee OA were highly effective in improving resting and walking pain with duration of symptom control up to 6 months, and a reduction in concomitant analgesia use of 30–50%. Furthermore, IA HA delayed the need for total knee replacement (TKR) surgery by approximately 2 years.” 

The ESCEO task force concludes:

“IA HA is an effective and safe treatment for long-term management of knee OA and may be a cost-effective treatment…”.