BPC 1:
En pacientes con sospecha clínica de osteoartritis (OA), no se deberían solicitar imágenes radiológicas de forma rutinaria para la confirmación diagnóstica.

BPC 2:
En pacientes con sospecha clínica de OA, considerar el uso de imágenes radiológicas si presentan alguna de las siguientes características que sugieren otro diagnóstico:

• Pacientes jóvenes con síntomas/signos de OA.
• Pacientes con historia de fractura confirmada.
• Pacientes con alteración del eje femorotibial.
• Pacientes con características atípicas: signos de inflamación articular, dolor marcado al reposo o en la noche, dolor rápidamente progresivo.
• Pacientes con pérdida de peso o síntomas constitucionales.

BPC 3:
En pacientes con sospecha de OA, realizar el diagnóstico clínico en aquellos que cumplan los siguientes tres criterios:

• Tener 45 años o más.
• Tener dolor articular persistente relacionado al uso de la articulación.
• No tener rigidez articular matutina, o tenerla por menos de 30 minutos.

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Recomendación 1:
En pacientes con OA, recomendamos brindar un plan individualizado de medidas de educación y autocuidado.
(Fuerza de la recomendación: Fuerte, Certeza de la evidencia: Moderada ⨁⨁⨁◯)

BPC 1:
Este plan debe ser brindado tanto a los pacientes como a sus cuidadores y familiares, e incluir:

• Información general sobre la OA: definición, pronóstico y opciones de tratamiento.
• Recomendaciones de autocuidado: disminución de peso, uso de calzado adecuado y realización de actividad física (ejercicios aeróbicos de bajo impacto y estiramientos).

BPC 2:
En adultos con OA, aplicar los tres principios de la toma de decisiones compartida (evidencia, valores y preferencias del paciente, y circunstancias clínicas) para acordar un plan con el paciente y sus familiares, explicando y discutiendo los beneficios y daños de las opciones de tratamiento.

BPC 3:
Sobre los seguimientos de rutina: evaluar de forma temprana a pacientes con OA (por medicina física y rehabilitación y, según el IMC, por nutrición) y realizar seguimiento, al menos anual, para monitorizar síntomas, evolución, efectividad del tratamiento y tolerancia. Si se detecta evolución desfavorable, referir al especialista.

BPC 4:
Según criterio clínico, en algunos pacientes con OA sintomática se puede realizar un seguimiento trimestral, especialmente en aquellos con dolor persistente, múltiples articulaciones afectadas, varias comorbilidades o uso de varios medicamentos.

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Recomendación 1:
En pacientes con OA, recomendamos indicar la realización de ejercicio físico.
(Fuerza de la recomendación: Fuerte, Certeza de la evidencia: Baja ⨁⨁◯◯)

BPC 1:
El ejercicio físico debe incluir fortalecimiento muscular local, estiramiento y actividad aeróbica general (especialmente de bajo impacto).

BPC 2:
El plan terapéutico de ejercicio físico, supervisado o no, debe ser individualizado según la edad, comorbilidades, gravedad del dolor o discapacidad para su aplicación institucional y domiciliaria.

BPC 3:
Enseñar una rutina de ejercicio físico al paciente para que pueda continuar en su domicilio al término del plan institucional.

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Recomendación 1:
En pacientes con OA que tienen sobrepeso u obesidad, sugerimos ofrecer intervenciones para lograr la pérdida de peso.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Baja ⨁⨁◯◯)

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BPC 1:
Si se requiere el uso de ortesis para disminuir el dolor o aumentar la adherencia al plan de ejercicio, buscar asesoramiento con Medicina Física y Rehabilitación.

BPC 2:
Como parte del manejo de OA en miembros inferiores, considerar el uso de calzado adecuado.

BPC 3:
Indicar dispositivos de asistencia (como bastones) en pacientes con dificultades específicas en actividades diarias.

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Recomendación 1:
En pacientes con OA que requieran manejo del dolor, sugerimos usar AINE orales.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Muy baja ⨁◯◯◯)

BPC 1:
Utilizar AINE solo cuando sea necesario para aliviar el dolor o facilitar la instauración de medidas no farmacológicas (como el ejercicio).

BPC 2:
Al indicar un AINE, prescribir la dosis mínima efectiva por el menor tiempo posible y de forma intermitente.

*Dosis recomendadas:

• Naproxeno: 550 mg inicialmente, luego 550 mg cada 12 horas o 275 mg cada 8-12 horas (máx. 1100 mg/día).
• Ibuprofeno: 200–400 mg, hasta 3 veces al día; intervalos mínimos de 4 a 6 horas; no exceder 1200 mg/24 horas.
• Indometacina: 25 mg cada 8 horas.

BPC 3:
Considerar las contraindicaciones y comorbilidades antes de iniciar un AINE.

*Contraindicaciones:

• Hipersensibilidad al fármaco o excipientes.
• Antecedentes de broncoespasmo, asma, rinitis o urticaria asociada a AINE.
• Historia de úlcera péptica o hemorragia gastrointestinal recurrente.
• Disfunción hepática grave.
• Insuficiencia renal grave.
• Insuficiencia cardíaca severa o deshidratación importante.
• Trastornos de la coagulación.
• Embarazo en el tercer trimestre.

BPC 4:
Al indicar un AINE oral, considerar el uso concomitante de un inhibidor de bomba de protones (IBP) en:

• Pacientes mayores de 65 años.
• Uso de AINE a dosis altas.
• Pacientes que usan concomitantemente glucocorticoides, anticoagulantes, o ácido acetilsalicílico.
• Antecedente de úlcera péptica no complicada.

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Recomendación 1:
En pacientes con OA que requieran manejo del dolor, sugerimos no usar paracetamol de forma rutinaria.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Baja ⨁⨁◯◯)

BPC 1:
Se podría considerar el uso de paracetamol en aquellos que no toleren AINE o tengan contraindicaciones.

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Recomendación 1:
En pacientes con OA que requieran manejo del dolor, sugerimos no usar tramadol como primer fármaco.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Baja ⨁⨁◯◯)

BPC 1:
En pacientes que no tengan alivio del dolor con AINE o paracetamol, se podría considerar el uso de tramadol según evaluación individual y comorbilidades.

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Recomendación 1:
En pacientes con OA, sugerimos no usar glucosamina ni condroitín sulfato para el manejo de la enfermedad.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Muy baja ⨁◯◯◯)

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Recomendación 1:
En pacientes con OA de rodilla con dolor que no responden a AINE, sugerimos considerar la aplicación de corticoide intra-articular para el manejo agudo del dolor.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Muy baja ⨁◯◯◯)

Recomendación 2:
En pacientes con OA de cadera con dolor que no responden a AINE, sugerimos considerar la aplicación de corticoide intra-articular bajo guía ecográfica.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Muy baja ⨁◯◯◯)

BPC 1:
Al aplicar un corticoide intra-articular, utilizar triamcinolona acetónido 40 mg para articulaciones de rodilla y cadera; dosis máxima 80 mg (2 articulaciones simultáneas).

BPC 2:
Explicar al paciente que el corticoide intra-articular solo proveerá alivio del dolor a corto plazo (2-10 semanas).

BPC 3:
No considerar el uso de corticoide intra-articular si no hay evidencia radiológica de OA e inflamación activa.

BPC 4:
Valorar la frecuencia y el tiempo total de administración; procurar un intervalo de al menos 4-6 meses entre aplicaciones.

BPC 5:
No utilizar corticoide intra-articular si se planea un reemplazo articular total en menos de 3 meses, por riesgo de infección de la prótesis.

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Recomendación 1:
En pacientes con OA, recomendamos no utilizar ácido hialurónico intraarticular.
(Fuerza de la recomendación: Fuerte, Certeza de la evidencia: Moderada ⨁⨁⨁◯)

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Recomendación 1:
En pacientes con OA, sugerimos no usar proloterapia para el manejo de la enfermedad.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Muy baja ⨁◯◯◯)

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Recomendación 1:
En pacientes con OA, sugerimos no indicar agentes físicos (ondas cortas, interferencial, TENS, láser, ultrasonido) como única medida para el manejo del dolor.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Muy baja ⨁◯◯◯)

BPC 1:
Según indicación del especialista en Medicina Física y Rehabilitación, se podrían utilizar agentes físicos para facilitar el inicio del ejercicio, cuando estén disponibles.

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Recomendación 1:
En pacientes con OA, sugerimos no usar acupuntura para el manejo de la enfermedad.
(Fuerza de la recomendación: Condicional, Certeza de la evidencia: Muy baja ⨁◯◯◯)

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BPC 1:
En pacientes con OA, considerar el tratamiento quirúrgico cuando las terapias farmacológicas y no farmacológicas no controlen adecuadamente el dolor y la limitación funcional.

BPC 2:
Para indicar tratamiento quirúrgico, se requiere opinión previa del médico reumatólogo y/o de medicina física y rehabilitación.

BPC 3:
Los pacientes referidos para manejo quirúrgico deben recibir terapia física de fortalecimiento muscular guiada por el especialista.

BPC 4:
En pacientes con indicación quirúrgica, evaluar y controlar factores asociados a peores resultados (ausencia de soporte social, ansiedad, depresión, dolor lumbar, sobrepeso/obesidad, hipotrofia muscular y comorbilidades como osteoporosis).

BPC 5:
En pacientes candidatos a cirugía, brindar información sobre:

• Beneficios y riesgos de la cirugía.
• Consecuencias de no realizar la cirugía.
• Consecuencias de la cirugía.
• Proceso de recuperación y rehabilitación postoperatoria.

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