Osteoarthritis
(2009)
Philippine Rheumatology Association
Rm. 1408 Cathedral Heights Bldg. Complex, St. Luke's Medical Center
E. Rodriguez Sr. Avenue, Quezon City
Telephone No.: (+632) 726-8875
E-mail: pra@pacific.net.ph/pra_office@yahoo.com
Website: www.philippinerheumatology.org
Osteoarthritis
Philippine Rheumatology Association
Rm. 1408 Cathedral Heights Bldg. Complex, St. Luke's Medical Center
E. Rodriguez Sr. Avenue, Quezon City
Telephone No.: (+632) 726-8875
E-mail: pra@pacific.net.ph/pra_office@yahoo.com
Website: www.philippinerheumatology.org
Board of Trustees
Officers 2008-2010
President Caroline G. Aroyo , MD
Vice-President Inocencio P. Alejandro, MD
Secretary Bernadette Heizel M. Reyes, MD
Treasurer Eric Jason B. Amante, MD
Board of Directors Leonila F. Dans, MD
Manuel Emerson Donaldo, MD
Jose Paulo P. Lorenzo, MD
Immediate Past President Evelyn O. Salido, MD
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Osteoarthritis
PRA Clinical Practice Guidelines for the Medical
The Philippine Rheumatology Asso- Management of Knee Osteoarthritis
ciation Clinical Practice Guidelines
Recommendations for Education
for the Medical Management of
Knee Osteoarthritis (OA) 1. There is insufficient evidence to recommend struc-
tured arthritis self-management programmes over
Ester Z. Gonzales-Penserga MD, for the Knee OA Clinical the usual clinic practice for the control of pain in
Practice Guidelines Technical Working Committee* knee OA.
• Level of Evidence: High
Osteoarthritis is the most common joint disease world-
wide. In the Philippines, its prevalence is 0.5% in indi- 2. Patient education consisting of physician advice and
viduals aged 20 years and above and increases to 11% educational/reading materials (usual clinic practice)
in the population aged 60 years and above (NNHeS, is recommended in the control of pain in knee OA.
2003). These figures are similar to foreign data. We are
therefore looking at roughly 10 million Filipinos with the • Level of evidence: Low (Expert Panel recommen-
disease. This number is expected to double in the next dation)
25 years (Summary Demographic Data for the Philip-
pines, US Census Bureau, International Database July, Recommendation for Weight Reduction
2003).This staggering projection compels us to look into
our treatment strategies for osteoarthritis. 3. Weight loss is recommended as a core treatment
for obese and overweight adults with knee OA. Five
There are several important guidelines for the treatment percent weight loss significantly improves pain and
of knee OA, including the American Rheumatology As- function in knee OA.
sociation (ACR) Guidelines for the Management of Os-
teoarthritis of the knees and hips, the European League • Level of evidence: High
of Associations for Rheumatology (EULAR) Treatment
Guidelines for OA (with several and on -going amend- Recommendations for Analgesics
ments to date), Singapore, and other individual countries.
Within countries, specialties like Orthopedic Surgery, 4. Paracetamol is recommended as first line drug
Family Physicians, Pain, etc., have likewise, developed therapy for reduction of mild knee OA pain using
guidelines for the treatment of OA. All these guidelines a maximum dose of 4 grams daily. However, close
agree on two important interventions and indications: monitoring for upper GI adverse events should be
physical measures as “cornerstone” of treatment and done for doses greater than 2 grams per day.
surgery for cases refractory to medical management.
• Level of evidence: High
The Philippine Rheumatology Association created a
Technical Working Committee tasked with identifying 5. Tramadol is recommended for the control of moder-
gaps in the existing guidelines and formulating evidence- ate pain and improvement of function in knee OA.
based recommendations for the medical management It is further recommended that patients be warned
of knee OA . of adverse events like dizziness and vomiting.
Methods: The Technical Working Committee listed • Level of evidence: High
specific treatment modalities for review, including those
already in existing recommendations and those which are Recommendation for NSAIDs
not, and in the process, identified the lack of evidence
-based recommendations for the use of complementary or 6. Oral NSAIDs and COXIBs up to 2 weeks duration
alternative medicine for knee OA. All randomized clinical are recommended for their small to moderate effect
trials, meta-analyses, systematic reviews of treatments in reducing exacerbations of knee OA pain and im-
for knee OA with outcomes for pain, function and adverse proving function, with no significant adverse events
events measured by WOMAC, Lequesne, SF 36, AIMs, among patients with no known renal, cardiovascular
HAQ, VAS, Likert scales were included. A search strategy and gastrointestinal risk factors.
was defined and MEDLINE search of Pubmed, OVID,
Cochrane databases as well as Herdin and local links • Level of evidence: High
to the Department of Science and Technology (DOST),
and hand search for publications in the Department of 7. Exercise caution in the use of these drugs among
Pharmacology Library, UP College of Medicine was done patients who are:
for articles published up to June, 2008. Twenty- five rec- • elderly
ommendations were formulated, presented to a Panel of • those at high risk for renal, cardiovascular and
Experts, reviewed and hereby submitted. gastrointestinal complications.
8. Topical NSAIDs are recommended for the control
of symptomatic or acute exacerbation of knee OA
and improvement of function and has less systemic
198
Osteoarthritis
side effects compared to oral preparations. traceutical preparations or other non-bioequivalent
formulation.
• Level of evidence: High
• Level of evidence: Low (Expert Panel recommen-
Recommendations for Intra-articular (IA) dation)
Steroids
Chondroitin
9. IA steroids, administered by experts, is recom-
mended as effective and safe in the treatment of 17. Chondroitin sulfate is not recommended for knee
moderate symptomatic exacerbations of knee OA osteoarthritis.
and improvement of function, with effects of up to
1-3 weeks. • Level of evidence: High
• Level of evidence: High Combination glucosamine and chondroitin sulfate
10. Further injections in case of recurrence should not 18. In general, the combination of glucosamine hydro-
exceed 3 times per year in the same joint. chloride and chondroitin sulfate is not recommended
for knee osteoarthritis
• Level of evidence: Low (Expert Panel recommen-
dation) • Level of evidence: Moderate
11. There is no data to support the role of oral steroids 19. There is no literature available on the combination
glucosamine sulfate and chondroitin sulfate for knee
in the treatment of knee OA.
OA.
Recommendations for IA Hyaluronic acid
Recommendation for Complementary and Alter-
(IAHA)
native Medicine (CAM)
12. IAHA, administered by experts in 3-5 weekly injec-
Spa or balneotherapy
tions is recommended for moderate pain reduction
and improvement of function in patients with moder- 20. There is insufficient evidence to recommend spa
ate knee OA. treatment for the control of pain and improvement
of function in knee OA.
IAHA is more effective than IA steroids for its longer
duration of pain control and improved function of up • Level of evidence: Low
to 5 – 13 weeks.
Tai Ch’i
• Level of Evidence: Moderate
21. There is insufficient evidence to recommend Tai ch’i
13. IAHA may be considered for subsets of patients with for the control of pain and improvement of function
moderate knee OA while awaiting more definitive in knee OA.
treatment (surgery).
• Level of evidence: Low
• Level of evidence: Low (Expert Panel recommen-
dation) Yoga
Recommendations for Glucosamine and Chon- 22. There is insufficient data to recommend yoga to
droitin control pain and improve function in knee OA.
Glucosamine • Level of evidence: Low
14. The use of pharmaceutical grade of glucosamine Acupuncture
sulfate is recommended for its small benefit on pain
reduction and improvement of function in patients 23. Manual or electroacupuncture is recommended as
with knee OA. additional therapy to achieve pain relief lasting a
few weeks among patients with moderate pain due
• Level of evidence: High to knee osteoarthritis.
15. The use of glucosamine hydrochloride is not recom- The procedure must be adequate and performed
mended for knee OA. by a trained and experienced acupuncturist.
• Level of evidence: Low (Expert Panel recommen- • Level of evidence: Moderate
dation)
Herbal preparations
16. Data from trials involving the pharmaceutical grade
form of the drug cannot be extrapolated to the nu- 24. The use of concentrated standardized ginger prepa-
Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users. 199
Osteoarthritis
ration is recommended for its moderate effect in the
control of pain and improvement of function in knee
OA. Patients should be warned of gastrointestinal
adverse reactions that can occur with this prepara-
tion.
• Level of evidence: Moderate
There is insufficient data on comfrey, Chinese
herbal recipe, Chinese pills, rose hip, devil’s claw
to recommend their use in knee OA.
25. Massage
There is insufficient evidence to recommend
massage (standard Swedish) for the treatment of
knee OA.
• Level of evidence: Low
* Evelyn O. Salido MD, Adora G.del Rosario MD, Heizel M. Reyes MD,
Emmanuel Perez MD, Annabelle Dytan MD, Auxencio Lucero MD,
Japit O Galagaran MD, Anna Regina Banatin MD, Noriezel Trinidad,
MD, Evan Glenn S. Vista MD, Gideon Caballes, MD, Eugene Uy MD,
Millicent Ong MD
200
Osteoarthritis
Recommended Therapeutics
The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's
reference, available drugs are listed under each therapeutic class. For drug information, please refer to the Philippine
Drug Directory System (PPD, PPDr, PPD Text, PPD Tabs).
Analgesics Diclogen Gel Mecid-A
Coxibs Diclowal/Diclowal Retard Medianon
Difenax Medianon Suspension
Etoricoxib
Arcoxia/Arcoxia AC Dolfastad Mefedon
Doloflam Mefenax
Drugmaker's Biotech Diclofenac Pacimic
Celecoxib
Fendil Penomor
Celcoxx
Lobafen Pharex Mefenamic Acid
Celebrex
Neo-Pyrazon Ponser
Celexib
Neurofenac Ponstan
Flamar
Sinochem Diclofenac sodium Ralgec
Pharex Celecoxib
Voltaren Revalan
Ritemed Mefenamic Acid
Paracetamol Ibuprofen Selmac
Alvedon
Advil Stangesic
Baropyrine
Dolan FP Tynostan
Biogesic
Faspic Zapan
Calpol/Calpol Six Plus
Idyl SR
Carpacet
Laberfen Meloxicam
Cetra
Crocin Medicol Cloxim
DLI Paracetamol Midol Meflam
Dolcet Melart
Dolexpel Ibuprofen/Paracetamol Melcom-15
Drugmaker's Biotech Paracetamol Alaxan Meloflam
Medgenol Alaxan FR Melora
Meforagesic Drugmaker's Biotech Paracetamol + Mobic
Napran Ibuprofen Moxen
Naprinol Fladexon Neoxicam
Neo-Kiddielets Muskelax Pharex Meloxicam
Opigesic Proflex
Pynal Relaxid Naproxen
Rexidol Restolax Agapro
Ritemed Paracetamol Restolax Forte Alpron
Saridon Selxan Drugmaker's Biotech Naproxen
Sinochem Paracetamol Flanax/Flanax Forte
Sinomol Indomethacin Naprosyn LLE/Naprosyn LLE Forte
Temperal Drugmaker's Biotech Indomethacin Pharex Naproxen
Tempra/Tempra Forte Vigel Cream Skelan
Tylenol
Ultragesic Ketoprofen Piroxicam
Drugmaker's Biotech Ketoprofen Drugmaker's Biotech Piroxicam
Paracetamol/Carisoprodol Orudis EC Feldene/Feldene Flash
Lagaflex Orudis IV Flamastat
Flaxine
Parcetamol/Orphenadrine Citrate Mefenamic acid Macroxam
Norgesic/Norgesic Forte Acidan Palpasin
Analcid Parixam
Paracetamol/Phenylpropanolamine/ Aprostal Pirostad
Arthran Proximax
Chlorphenamine maleate
Atmose
Norcolds
Befidan Proglumetacin
Calibral Afloxan
Paracetamol/Vitamin B-Complex DLI Mefenamic acid
Dolo-Neurobion Dolfenal Tramadol
Dolmetine Dolmal
NSAIDs Dolsten Dolotral
Aceclofenac Drugmaker's Biotech Mefenamic acid Gesidol
Clanza Eurostan Milador
Fenexan Milador Inj
Diclofenac Gardan Radol
Abicfen Gisfen Relidol
Cataflam Icelax Siverol
Cataflam QS Istan TDL
Diclogen Kramon Tolma
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Osteoarthritis
Tradonal
Tramal
Tramid
Tramundin
Tramadol/Paracetamol
Cetra
Dolcet
Glucosamine sulfate
Viartril-S
Chondroitin
Intraarticular Steroid
202
