Osteoarthritis (OA) is the most common form of arthritis and patients with OA have pain that typically worsens with weight bearing activity and improves with rest, as well as morning stiffness and gelling of the involved joint after periods of inactivity. On physical examination, they often have tenderness on palpation, bony enlargement, crepitus on motion, and/or limitation of joint motion. Unlike the case with rheumatoid arthritis (RA) and other inflammatory arthritis, inflammation, if present, is usually mild and localized to the affected joint. Joint symptoms and/or back pain were amongst the top 10 commonest reasons for general practice consultation and cases attending Accident and Emergency departments classified as primary care cases.^1,2

The epidemiology of osteoarthritis of the hip and knee differs considerably between Caucasian and Chinese populations. Hoaglund et al observed the prevalence of osteoarthritis of the hip to be 1 percent or lower in Chinese and the prevalence of osteoarthritis of the knee to be 13 percent in Chinese women and 5 percent in Chinese men.³ Such findings were confirmed in a recent study, which showed the rate of hip replacement in American Chinese to be 10 percent of the rates in American Caucasians.⁴ The racial difference in the prevalence of osteoarthritis may be attributable to both genetic and lifestyle factors. Constitutional and lifestyle factors may also be important in the aetiology of osteoarthritis.

Low education and socioeconomic class were associated with more severe disease while OA affected family or close relationships in 44%.⁵ The average cost incurred as a result of side effects of medication is similar to the average cost of medication itself. Excluding joint replacement, the direct costs ranged from Hong Kong (HK) dollar $11,690 to $40,180 per person per year and indirect costs, HK$3,300-$6,640. The direct costs are comparable to those reported in Western countries; however, the total cost expressed as a percentage of gross national product is also much lower in Hong Kong. The socioeconomic impact of OA in the Hong Kong population is comparable to that of Western countries, but the economic burden is largely placed on the government.

Although there is no known cure for OA, treatment designed for the individual patient can reduce pain, maintain and/or improve joint mobility, and limit functional impairment. The goals of the contemporary management of the patient with OA continue to include control of pain and improvement in function and health-related quality of life, with avoidance, if possible, of toxic effects of therapy.

The Family Medicine Unit of Department of Community and Family Medicine, the Chinese University of Hong Kong, has established an ad hoc committee to review the recent developments in the field and update the recommendations.⁶ The goal of these recommendations is to improve patient outcomes in the primary care setting by maximizing treatment efficacy and minimizing rates of adverse events. The committee followed the principles of evidence-based medicine as used in the process of making clinical decisions.⁷ This guideline addresses the appropriate use of non-pharmacological and/or pharmacological treatment of patients with osteoarthritis in the primary care setting. General practitioners/family physicians must use their professional knowledge and judgement when applying guideline recommendations to the management of individual patients. They should note the information, contraindications, interactions, and side effects contained in the MIMS Annual Hong Kong.

Differences in Hong Kong OA Management Guidelines and the EULAR and ACR guidelines include the following:^8,9

1. The guideline is based on the most updated information available (up to May 2004) (e.g. the updated information on the side effects of the COX-2 inhibitors on the cardiovascular system) and well-organized base on the drugs' effectiveness, side-effects and usage, so that the physicians can practically use it easily (its readability should be higher than ACR and contains more information on the usage of the drugs' than the EULAR).
2. Although no meta-analysis had been performed, the evidence was classified similar to the EULAR guideline, which is similar to an evidence based review.
3. The Hong Kong guideline focuses on both the pharmacological and non-pharmacological management strategies of OA hip and knee whilst the ACR guideline also covered the surgical management strategies and the EULAR only concentrated on OA knee.
4. The EULAR and ACR guidelines were published in two specialist journals. However, the majority of the burden of OA is managed in primary care, it is more appropriate that the guidelines be targeted to a primary care audience.

The guidelines are divided into three parts for dissemination. The first part is a summary of recommendations for managing OA knee and hip in primary care setting. The second part is a full report details the methodology and findings on which the recommendations are based. The last part is a patient education booklet (in Chinese) that will facilitate the implementation of the guidelines. The first part of these guidelines is included as inserts in this issue of The Hong Kong Practitioner. The full report can be assessed through http://www.cuhk.edu.hk/med/cmd/

The key messages of the guidelines are as follow:

• Doctors in primary care must take a more active role in communicating with patients about available treatment options, their benefits and risks;
• Non-pharmacological interventions should form an integral part of the treatment of OA but the optimal treatment requires combination with pharmacologic measures;
• Acetaminophen is recommended as the first-line treatment for mild-to-moderate pain of OA, because of its efficacy, safety and cost and it is the preferred essential component of long term pain control;
• If acetaminophen is inadequate, alternative treatment options include NSAIDs, CSIs, SYSADOAs, opioids and injection treatments.