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Osteoarthritis Cartilage. 2019 Nov;27(11):1578-1589. doi: 10.1016/j.joca.2019.06.011. Epub 2019 Jul 3.

OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis.

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Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, MA, USA. Electronic address:
Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, MA, USA.
Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Nottingham, UK; MRC Lifecourse Epidemiological Unit, University of Southampton, Southampton, UK.
Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne, Carlton, Victoria, Australia.
Department of General Practice, Erasmus MC - University Medical Centre Rotterdam, Rotterdam, the Netherlands; Department of Orthopedics, Erasmus MC - University Medical Centre Rotterdam, Rotterdam, the Netherlands.
Duke Molecular Physiology Institute and Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
Dept. of Clinical Sciences, Orthopedics, Lund University, Lund, Sweden.
Centre for Musculoskeletal Outcomes Research (CMOR), Dept. of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
Dept. of Orthopedic Surgery, McMaster University, Ontario, Canada.
Grupo de Investigación de Reumatología, INIBIC-Hospital Universitario, A Coruña, La Coruña, Spain; CICA-INIBIC Universidad de A Coruña, A Coruña, La Coruña, Spain.
National Institute of Rehabilitation, México City, Mexico; National Autonomous University of México, México City, Mexico.
Dept. of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
Arthritis Clinic and Research Center, Peking University People's Hospital, Peking University, Beijing, China.
Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
The Immunopharmacology Research Group, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland.
Institute for Medical Science in Sports, Osaka Health Science University, Osaka, Japan.
Dept. of Physical Therapy, STAR University of Delaware, Newark, DE, USA.
Division of Sports Medicine, Drexel Sports Medicine, Philadelphia, PA, USA.
Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK; University Hospitals of Coventry and Warwickshire, Coventry, UK.



To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data.


We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation.


Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node.


These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.


Clinical practice guidelines; Hip; Knee; Non-surgical management; Osteoarthritis


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