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I welcome the publication of the EULAR recommendations for the management of knee osteoarthritis by the EULAR Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).1 However, it is out of date and has been superseded by other more up to date publications such as the recommendations for the medical management of osteoarthritis of the hip and knee by the American College of Rheumatology (ACR) Subcommittee on Osteoarthritis Guidelines2 and another review of the medical management of osteoarthritis.3 The newer COX-1 sparing non-steroidal anti-inflammatory drugs, rofecoxib and celecoxib are not discussed in the EULAR recommendations, but they have been included in the other reviews.2 3
My second criticism of the report is that it contains statements such as “ SYSADOA... may possess structure modification properties”, which is misleading and may lead to widespread use of these drugs in the absence of good evidence.
Although the Annals of the Rheumatic Diseases is the official EULAR journal, EULAR reports should be peer reviewed before publication. The ACR recommendations for the management of osteoarthritis of the hip and knee were only accepted in a revised format.2 Two of the authors of the review in the BMJ3 are also coauthors of the EULAR report.
We thank Dr Jawad for his interest in the EULAR recommendations.1-1 The fact that the literature search ended at December 1998, excluding evidence based discussion of COX-2 inhibitors, is clearly highlighted and discussed in the paper. Unfortunately, a finite end point needs to be set on any thorough evidence based review, and even the ACR document1-2 was of necessity four months out of date by the time it was published. However, the important strengths of the EULAR document compared with the ACR report are:
1 It used a structured evidence based format rather than just consensus statements.
2 It had input from 23 experts from 12 countries, as opposed to four expert Americans.
3 It undertook additional analyses on published trials to calculate effect sizes and numbers needed to treat where sufficient data were available (that is, it provided new data).
4 The search included surgery and treatments such as topical non-steroidal anti-inflammatory drugs, which are not licensed in the USA and which were excluded from the ACR paper.
5 It provided data on the “epidemiology” and quality of clinical trials in knee osteoarthritis (OA) and highlighted important questions that (still in 2001) need to be addressed by future research.
Unlike the review by Walker-Bone and three other coauthors from Southampton,1-3 the EULAR report encompassed both medical and surgical treatments, and carefully examined the literature in response to specific clinically relevant questions rather than in an attempt to produce a pragmatic algorithm. We also calculated effect sizes rather than estimates of efficacy, and did not extrapolate treatment data for the knee (the site to which most data relate) to other joint sites. The difference in outcome from these two contrasting approaches is shown, for example, by the recommendation in theBMJ report to consider intra-articular steroid injection only if an effusion is present, whereas the EULAR committee concluded there is no clear evidence to justify a knee effusion as a predictor of response to such treatment.
The qualified statement that “SYSADOAs may possess structure modification properties, but more studies, using standardised methodologies are required” was based on available evidence and made without prejudice. To introduce bias by ignoring published reports on such treatments would indeed be misleading and against all the ethos of evidence based practice.
Although this was a paper that was drafted, edited, and remodified by 21 European experts in OA, the manuscript was peer reviewed by two additional referees after its submission to theAnnals.
The committee are delighted with the growing interest in the management of OA and that three contrasting reviews were published on the topic in 2000. We, of course, realise the current interest in highly selective COX-2 inhibitors. Importantly, however, the three reports fully concur with respect to the important elements of OA management—the non-pharmacological interventions. They also all agree that paracetamol remains the oral analgesic to try first and, if successful, is the preferred long term oral analgesic.
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