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Non-surgical management of knee osteoarthritis: comparison of ESCEO and OARSI 2019 guidelines


Knee osteoarthritis (OA) is a heterogeneous disease associated with substantial effects on quality of life, and its clinical management is difficult. Among the several available guidelines for the management of knee OA, those from OARSI and ESCEO were updated in 2019. Here, we examine the similarities and differences between these two guidelines and provide a narrative to help guide health-care providers through the complexities of non-surgical management of knee OA. OARSI and ESCEO both recommend education, structured exercise and weight loss as core treatments, topical NSAIDs as first-line treatments and oral NSAIDs and intra-articular injections for persistent pain. Low-dose, short-term acetaminophen, pharmaceutical grade glucosamine and chondroitin sulfate are recommended by ESCEO whereas OARSI strongly recommends against their use (including all glucosamine and chondroitin formulations). Despite this difference, the two guidelines are consistent in the majority of their recommendations and provide useful treatment recommendations for individuals with OA and health-care providers.

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Fig. 1: Summary of voting procedures for the OARSI and ESCEO working groups.
Fig. 2: Simplified OARSI and ESCEO treatment algorithms for the non-surgical management of knee OA in patients without comorbidities.


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Authors’ statement: the diverse views and opinions expressed in this article represent the outcomes of a joint working group, consisting of current members of the Osteoarthritis Research Society International (OARSI) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), which examined the similarities and differences between the 2019 OARSI and ESCEO guidelines for the management of knee OA. The working group was entirely funded by ESCEO. To support its educational and scientific activities, ESCEO receives unrestricted educational grants from non-governmental organizations, not-for-profit organizations, and non-commercial and corporate partners. The choice of topics, participants, content and agenda of the working group, as well as the writing, editing, submission and reviewing of the manuscript are the sole responsibility of ESCEO, without any influence from third parties. ESCEO is supported by the Chair for Biomarkers of Chronic Diseases and the International Scientific Partnership Program (ISPP#0111) at King Saud University, Riyadh, Saudi Arabia.

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T.A.P., N.K.A., R.R.B. and O.B. researched data for the article. T.A.P. and N.K.A. wrote the manuscript. All authors made a substantial contribution to discussion of content and review/editing of the manuscript before submission.

Corresponding author

Correspondence to Thomas A. Perry.

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Competing interests

N.K.A. declares that he has received grants and personal fees from Merck, and personal fees from Flexion, Regeneron, Pfizer, and Eli Lilly. R.R.B. is supported by the NIH National Center for Complementary and Integrative Health (K23AT009374). O.B. declares that he has received grants from Biophytis, IBSA, MEDA, Servier, SMB and Theramex. C.C. declares that he has received lecture fees and honoraria from Amgen, Danone, Eli Lilly, GSK, Kyowa Kirin, Medtronic, Merck, Nestlé, Novartis, Pfizer, Roche, Servier, Shire, Takeda and UCB, outside the submitted work. I.K.H. declares that she has received honoraria from Abbvie and a research grant from Pfizer, outside the submitted work. M.C.H. declares that he has acted as a consultant, including attending at Advisory Board meetings, for Bone Therapeutics, Bristol Myers Squibb, Eli Lilly, EMD Serono, Gilead, GlaxoSmithKline, IBSA Institut Biochimique SA, Novartis Pharma AG, Noven Pharmaceuticals, Pfizer, Regenosine, Samumed LLC, Theralogix LLC and Vizuri Health Sciences, and that he has received royalties from Elsevier (for his roles as editor of Rheumatology and Editor-in-Chief of Seminars in Arthritis and Rheumatism) and Wolters Kluwer (UpToDateTM) outside the submitted work. T.E.M. declares that he has acted as a consultant for Samumed, Kolon TissueGene, Pfizer, Sanofi, Regeneron, Noven, Remedium-Bio. A.M. declares that he has acted as a consultant for Abbvie, Aché (Aché Laboratórios Farmacêuticos), Artialis SA, Flexion Therapeutics, Galapagos, Genacol, GSK Consumer Healthcare, IAG, Kolon TissueGene, Pfizer, Pfizer Consumer Healthcare, Servier, Sterifarma, Sanofi and Pacira Biosciences, has received research funding from the European Commission (FP7, IMI, Marie Skłodowska-Curie, ES Struktūrinės Paramos), Versus Arthritis (formerly Arthritis Research UK) and has initiated research contracts with Merck KGaA and Kolon TissueGene, and has received speaker’s fees from Bioiberica SA, the Korean Society for Osteoarthritis and Cartilage Repair, the American College of Rheumatology, the Spanish Society of Rheumatology, the Heilongjiang Rheumatology Association and the Zhujiang Hospital of Southern Medical University. J.-Y.R. declares that he has received grants and personal fees from IBSA-Genevrier, Mylan, and Radius Health, grants from CNIEL, and personal fees from Dairy Research Council and Pierre Fabre, outside of submitted work. T.A.P. declares no conflicts of interest.

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Nature Reviews Rheumatology thanks E. Maheu and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Arden, N.K., Perry, T.A., Bannuru, R.R. et al. Non-surgical management of knee osteoarthritis: comparison of ESCEO and OARSI 2019 guidelines. Nat Rev Rheumatol 17, 59–66 (2021).

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