gul\ideline knee

  • Published on
    24-Mar-2016

  • View
    226

  • Download
    9

Embed Size (px)

DESCRIPTION

uideline knee edit november 2011

Transcript

  • .. 2553

  • (osteoarthritis or osteoarthrosis)

    (clinical practice guideline)

    (clinical practice guideline)

    1

  • 15 (clinical practice guideline)

    ( )

    2

  • 1. ..

    - Rotta Pharm, TRB, Bangkok Drugs, MSD, Zimmer, Smith & Nephew - proposal Bangkok drugs, Rotta Pharm

    2. ... 3. .... 4. ... 5. ....

    - Pfizer, TRB 6. . 7. ..

    - , Moderator Rotta Pharm.

    8. . 9. . 10. . 11. . 12. . 13. . 14. . 15. . 16. ..

    3

  • (Strength of Recommendation)

    ++ (cost effective) (strongly recommend)

    + (recommend)

    +/- (neither recommend nor against)

    - (against)

    - - (strongly against)

    (Quality of Evidence)

    1 1.1 (systematic review) -

    (randomize-controlled clinical trials) 1.2 - 1 (a well-

    designed, randomize-controlled, clinical trial) 2

    2.1 (non-randomized, controlled, clinical trials)

    2.2 (well-designed, non-randomized, controlled clinical trial)

    2.3 (cohort) (case control analytic studies) /

    4

  • 2.4 (multiple time series) .. 2480

    3 3.1 (descriptive studies) 3.2 (fair-designed, controlled clinical trial)

    4 4.1

    (consensus) 4.2

    2

    (anecdotal report) (strength of recommendation) (prolonged life) (decreased morbidity) (improved quality of life) ( / ) 1 ++ ++ 1 ( 50 +/-) Papanicolaou

    5

  • ++ 2

    CT / MRI brain ++ ( +/-) +/- (1)

    (2) (3)

    (4) (5)

    12

    1 2 ( ) ++

    (systematic review and consensus of peer reviewers)

    6

  • /

    5

    (1)

    (2)

    (3) / (

    ) 5

    (1) (safety) (2) (efficacy) (3) (effectiveness) (4) (benefit of population and entire society) (5) (efficiency)

    1. (safety)

    (safety monitoring program: SMP) ( NNH: number needed to harm)

    2. ( efficacy) / ( NNT: number needed to treat)

    7

  • 3. (effectiveness) / / /

    3.1 3.2

    3.3 3.4 4. (benefit of population and entire

    society) / (utility)

    5. (efficiency) 4

    5 (- - , -, +, + ++) (relative weight)

    :-

    8

  • 1 ++ ( 5 +7 +10), --( 5 -7 -10) / / ( ) 2 :- 2.1 1 : - (randomize-controlled,

    clinical trial) 1 2.2 2 : (non-randomized, controlled,

    clinical trial) 2.2.1 (cohort) 2.2.2 (case-control) 2.2.3 (multiple-time series) adrenaline

    1 2 ( ) ++ ( 5 +9 +10) -- ( 5 -9 -10)

    2 + ( 5 +3 +6), -( 5 -3 -6) / / ( ) () / / 1 :- 2.1 1 ( 1 1 , 2 2 )

    2.2 3 / 4

    3 +/-( 5 -2 +2)

    9

  • () :- 3.1 ()

    3.1.1 3.1.2 3.1.3 (surrogated end-point) 3.1.4 (safety monitoring program : SMP) 3.1.5 .

    3.2 ( 1 / 2) 3.3

    . 3.4 (ultimate

    end points) 3.5

    10

  • .. 1 .............. 4 .. 13 . 14 24 .. 25 .. 26 . 26 27 . 28 . 28 . 29 29 30

    .. 30 .. 34 .. 42

    . 48 ..................................................................... 49 .. 49 51 .. 70

    11

  • 1 . 72 2 74 3 .. 78 4 .. 82 1 13 1 (Kellgren-Lawrence radiographic grading scale) ...... 29

    12

  • 1

    Heamatologic Serologic, synovial fluid study Bacteriologic studies Radiologic/imaging studies Arthroscopic examination and biopsy Treatment follow investigation findings

    No response

    No response within 3 months

    OA grade 2-3 or grade 4 (if surgery contraindicated)

    OA grade 4 (deformity and/or instability)

    Effusion; Intra-articular steroid injection SYSADOA

    No risk GI risk Renal risk CVS risk

    Not improved or regular need NSAIDs > 6 weeks or intolerance to NSAIDs

    Opioid + NSAIDs Opioid

    NSAIDs + PPI

    NSAIDs

    X-ray

    Consult rheumatologist, orthopaedist, physiatrist

    No improvement

    Clinical Diagnosis of Osteoarthritis of knee

    Non-pharmacological treatment (education, weight reduction, exercise, knee brace, accupuncture)

    + Acetaminophen or topical NSAIDs or capsaicin

    Mechanical symptom/lock, loose body

    OA grade 2-3

    Continue SYSADOA for 6 months

    response

    Arthroscopic surgery

    Medial or lateral joint line tenderness Meniscus tear

    High demand Medial compartment OA

    Lower demand Medial compartment OA

    Tricompartmental osteorthritis

    Knee arthroscopy Meniscus debridement

    High tibial osteotomy

    Unicompartmental arthroplasty

    Total knee arthroplasty

    Re-evaluate

    Not consider for surgery

    Consider surgery Discontinue SYSADOA

    COX-2 inhibitor

    Re-evaluation and investigations

    13

  • (

    ++)

    ++

    ++

    +/-

    ++

    ++

    +8

    ++

    1.2

    1.2

    1.2

    7-9

    10-1

    1 12

    (

    -)

    (reg

    ular te

    lepho

    ne co

    ntact)

    ++

    ++

    - --

    --

    -1

    -

    1.1

    1.1

    10-1

    5 10

    -15

    (

    ++)

    23

    ./

    ..

    5

    ++

    ++

    ++

    ++

    ++

    +10

    ++

    1.1

    1.1

    1.1

    4-5,

    16-

    18

    4-5,

    16-

    184-

    5

    14

  • (

    ++)

    (

    )

    (

    varus

    )

    (va

    lgus)

    (

    knee

    brac

    e / su

    pport

    )

    ++

    ++

    + +

    + +7

    ++

    1.1

    1.1

    1.1

    19-2

    0 19

    -20

    19

    (

    ++)

    ++

    ++

    + +

    + +7

    ++

    1.1

    1.1

    1.1

    3 3

    (

    -)

    (

    patel

    lar ta

    pe)

    (

    )

    +/-

    + -

    --

    --

    -4

    -

    1.1

    1.1

    1.1

    24-2

    7 24

    -27

    15

  • (

    +/-)

    (

    latera

    l/Med

    ial he

    el we

    dge)

    (m

    edial

    / lat

    eral c

    ompa

    rtmen

    t)

    +/-

    +/-

    +/-

    +/-

    - -1

    +/

    -

    4 4

    4

    21-2

    3 21

    -23

    21

    (

    ++)

    (

    adjun

    ct the

    rapy)

    ++

    ++

    + +

    + +7

    ++

    1.1

    1.2

    1.2

    28-3

    1 28

    -31

    30

    (

    ++)

    (pain

    relie

    vers

    aceta

    mino

    phen

    , non

    -stero

    idal a

    nti-in

    flamm

    atory

    drugs

    : NSA

    IDs)

    3

    *

    ++

    ++

    ++

    ++

    ++

    +10

    ++

    1.1,

    2.2

    1.

    1 1.

    1,3

    1.1,

    3

    1.1

    32-4

    9 37

    -39

    37-3

    9

    *

    (1

    ) Reg

    ular

    eth

    anol

    con

    sum

    ptio

    nin

    exce

    ss o

    f 21

    units

    /wee

    k i

    n m

    ales

    , 14

    units

    /wee

    k in

    fem

    ales

    , (2)

    Reg

    ular

    use

    of e

    nzym

    e-in

    duci

    ng d

    rugs

    (car

    bam

    azep

    ine,

    phe

    nyto

    in, p

    heno

    barb

    itone

    , rifa

    mpa

    cin)

    (

    3) C

    ondi

    tions

    cau

    sing

    glu

    tath

    ione

    dep

    letio

    n (m

    alnu

    tritio

    n, H

    IV, e

    atin

    g di

    sord

    ers,

    cyst

    ic fi

    bros

    is )

    16

  • (

    +/-)

    (to

    pical

    NSAID

    s)

    + +

    + +/

    - +/

    - +3

    +/

    -

    3 3

    3

    57-6

    6 57

    -66

    57-6

    6

    :

    (

    +

    /-)

    (

    topica

    l NS

    AIDs)

    (

    +)

    (non

    selec

    tive o

    ral N

    SAID

    S plu

    s gas

    tro-pr

    otecti

    ve ag

    ent)

    +/-

    ++

    + +

    + +5

    +

    3 3

    3

    52-5

    3 4

    (

    +/-

    )

    -2

    (cyclo

    oxyg

    enas

    e-2 in

    hibito

    rs)

    (1

    )

    60

    , (2)

    (3)

    (4

    )

    +/-

    ++

    +/-

    +/-

    +/-

    +2

    +/-

    3 3

    3

    50-5

    1 4

    22

    :

    (

    +/-)

    -2

    (cyclo

    oxyg

    enas

    e-2 in

    hibito

    rs)

    17

  • (

    +)

    (topic

    al ca

    psaic

    in)

    + ++

    +

    + +

    +6

    +

    1.1

    1.1

    1.1

    1.

    2

    54-5

    6 54

    -56

    54

    56

    (

    +/-)

    - +

    + +/

    - +/

    - +1

    +/

    -

    2.1

    2.1

    2.1

    67-6

    9 67

    -68

    69

    :

    (

    -)

    (

    +/-)

    (