Osteoarthritis Research Society International (OARSI) Classification and Guidelines

Introduction

As the group uniquely representing the field of osteoarthritis, the Osteoarthritis Research Society International (OARSI) has taken up a mandate to promote and advance research for the prevention and treatment of OA, a task that includes evaluating therapies and developing consensus statements and guidelines in respect of the medical treatment of OA. Research into OA therapeutics is currently highly active, so OARSI has also recognized the need to keep its guidelines current though repeated iterations of its update and consensus-building activities.

Development of Consensus for Treatment Guidelines

This process was initiated in 2006 under the leadership of Professor George Nuki and Dr. Weiya Zang. Four laborious steps were completed from 2006 to 2009, which included: a critical appraisal of prior guidelines from other societies and groups, a systematic review of the evidence up until January 2006 [1], development of consensus and treatment recommendations through a Delphi process among experts [2], and an update of the current evidence through January 2009 [3]. The general approach was to seek the highest level of evidence for each treatment modality and then present these data to the expert panel to generate consensus scores around a series of clinical therapeutic propositions. In fact, for some areas, the investigator group also performed data pooling of individual trial results, thus adding to the quality and body of available evidence on OA therapeutics. As such, the approach ultimately generated data-driven synthesis of the available evidence by experts. The endeavor produced a number of notable findings, including evidence for declining effects sizes for glucosamine and acetaminophen, evidence for toxicity of acetaminophen, and negative evaluations of procedures such as arthroscopic debridement. The ensuing publications rank highest among the list of downloads from the Osteoarthritis & Cartilage journal website, an indication of the level of interest and importance of this exercise.

With the elapsing of some time and the publication of substantially more OA therapeutic studies, OARSI has embarked on updating the evidence and reassessing expert opinion of the current evidence base. OARSI has, therefore, convened a new panel to accomplish this process using the established methodology. Conflict of interest, which will be treated by disclosure and censorship (where applicable), is a key factor in assembling an expert panel. Another critical component is broad representation of the constituents, so the new panel includes experts from across the globe: rheumatologists, primary care physicians, allied health professionals, methodologists, and patient representatives. The evidence update will be completed, as before, under the experienced guidance of Dr. Zhang and Prof. Nuki. Although the exercise will focus on updating the current propositions, the committee will have the opportunity to refine these if deemed necessary to optimize their relevance. In addition, the committee will consider alternative formulations such as an algorithmic approach, or a ranking of the treatment approaches as has been promulgated by other clinical guideline committees such as NICE.

Current and Future Challenges

The evidence update is now in progress, in preparation for the first face-to-face meeting of the new committee at the 2011 Annual OARSI meeting in San Diego. This will be followed by a series of Delphi steps to clarify understanding of the propositions, followed by voting on their content. The subsequent statistical analysis will provide data on the level of consensus and the mean strength of recommendation for each proposition.

The aim to develop and maintain a continually updated set of OA treatment guidelines is an ambitious and burdensome goal. Repeated iterations run the risk of delays due to inertia, the difficulty in evaluating accumulated evidence during a short period prior to each consensus meeting, and consequential time creep in the publication of the product. This is a challenge that could potentially be reduced by developing a process for continual updates of the evidence base aided by technological enhancements to permit real-time queries of the data and, perhaps, online applications to facilitate consensus measurement.