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Semin Arthritis Rheum. 2016 Feb;45(4 Suppl):S3-11. doi: 10.1016/j.semarthrit.2015.11.010. Epub 2015 Dec 2.

A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis-From evidence-based medicine to the real-life setting.

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Support Unit in Epidemiology and Biostatistics, Department of Public Health, Epidemiology and Health Economics, University of Liège, CHU Sart Tilman, Liège 4000, Belgium. Electronic address:
MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK.
Osteoarthritis Research Unit, University of Montreal Hospital Research Centre (CRCHUM), Montreal, Quebec, Canada.
Rheumatology Department, AP-HP, Saint-Antoine Hôpital, Paris, France.
Rehabilitation Unit, Rheumatology Department, Hôpital Cochin, AP-HP, INSERM UMR-S 1124, Université Paris Descartes, Paris, France.
CEDOC, Department of Rheumatology, Faculdade de Ciências Médicas, Universidade Nova de Lisboa/CHLO, EPE-Hospital Egas Moniz, Lisbon, Portugal.
Department of Internal Medicine, University of Florence, Florence, Italy.
WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
David Geffen School of Medicine, University of California, Los Angeles, CA.
Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; Geriatric Research, Education and Clinical Center, Baltimore, MD; Health Care System, Baltimore, MD.
Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium.


The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) published a treatment algorithm for the management of knee osteoarthritis (OA) in 2014, which provides practical guidance for the prioritization of interventions. Further analysis of real-world data for OA provides additional evidence in support of pharmacological interventions, in terms of management of OA pain and function, avoidance of adverse events, disease-modifying effects and long-term outcomes, e.g., delay of total joint replacement surgery, and pharmacoeconomic factors such as reduction in healthcare resource utilization. This article provides an updated assessment of the literature for selected interventions in OA, focusing on real-life data, with the aim of providing easy-to-follow advice on how to establish a treatment flow in patients with knee OA in primary care clinical practice, in support of the clinicians' individualized assessment of the patient. In step 1, background maintenance therapy with symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) is recommended, for which high-quality evidence is provided only for the prescription formulations of patented crystalline glucosamine sulfate and chondroitin sulfate. Paracetamol may be added for rescue analgesia only, due to limited efficacy and increasing safety signals. Topical non-steroidal anti-inflammatory drugs (NSAIDs) may provide additional symptomatic treatment with the same degree of efficacy as oral NSAIDs without the systemic safety concerns. Oral NSAIDs maintain a central role in step 2 advanced management of persistent symptoms. However, oral NSAIDs are highly heterogeneous in terms of gastrointestinal and cardiovascular safety profile, and patient stratification with careful treatment selection is advocated to maximize the risk:benefit ratio. Intra-articular hyaluronic acid as a next step provides sustained clinical benefit with effects lasting up to 6 months after a short-course of weekly injections. As a last step before surgery, the slow titration of sustained-release tramadol, a weak opioid, affords sustained analgesia with improved tolerability.


Chondroitin; Glucosamine; Hyaluronic acid; Knee osteoarthritis; Non-steroidal anti-inflammatory drugs; Symptomatic slow-acting drugs for osteoarthritis (SYSADOAs); Tramadol

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