To help clinicians manage the increasing number of patients with osteoarthritis (OA), the American College of Rheumatology (ACR) revised its guidelines for using non-pharmacologic and pharmacologic therapies in OA of the hand, hip, and knee. Published in an issue of Arthritis Care & Research, the guidelines update recommendations from 2000.
According to the ACR, management of OA should begin with treatments that are beneficial and have the lowest possible risk. Prior to recommending prescription medication and surgery, low-risk modalities (eg, weight loss and exercise) should be attempted. Treatments with greater risk may be used when simpler treatments fail.
Potential treatment modalities for hand OA include an assessment of activities of daily living, use of assistive devices, joint protection techniques, thermal agents, and trapeziometacarpal joint splinting. Oral and topical NSAIDs, topical capsaicin, and tramadol are other treatment modalities for hand OA, but opioids and intra-articular therapies are not recommended. Topical NSAIDs are preferred to oral administration in patients aged 75 and older, thus putting an emphasis on using these agents conservatively when possible.
“New therapies for OA and additional information on the safety and acceptability of existing therapies have emerged.”
For knee OA, aerobic or resistance land-based exercise, aquatic exercise, and weight loss are strongly recommended in the guideline update. Conditionally recommended modalities include self-management programs like manual therapy with supervised exercise, tai chi, and wedged insoles. For moderate to severe pain in patients who do not wish to undergo joint replacement, acupuncture and transcutaneous electrical nerve stimulation (TENS) are recommended. Conditionally recommended pharmacologic modalities include acetaminophen, oral and topical NSAIDs, tramadol, and intra-articular corticosteroid injections. Glucosamine, chondroitin sulfate, and topical capsaicin were conditionally not recommended.
Few trials have been performed for treating hip OA, which pushed the ACR guideline panel to recommend that patients with this condition be treated in a similar fashion to those with knee OA.
Implementing Osteoarthritis Guidelines
Considering the large impact of OA on physical and psychological health, it’s important for physicians to be aware of all treatment options. A shared decision-making process may improve the quality of care and patient satisfaction, as well as reduce liabilities for health professionals. To assist clinicians in implementing the ACR guidelines, the Cochrane Musculoskeletal Review Group has developed a decision aid. It summarizes the benefits and risks of various modalities discussed in the ACR guidelines. When used in combination with clinician expertise and patient preferences, the guidelines will hopefully help clinicians further reduce pain and improve function in OA sufferers.
View full guidelines here.
Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012;64:465-474. Available at: http://www.rheumatology.org/practice/clinical/guidelines/PDFs/ACR_OA_Guidelines_FINAL.pdf#search=”ACR OA guidelines”.
American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum. 2000;43:1905-1915.
Zhang W, Doherty M, Arden N, et al. EULAR evidence based recommendations for the management of hip osteoarthritis: report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2005;64:669-681.
Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2007;66:377-388.
Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-162.
American Academy of Orthopaedic Surgeons. American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of osteoarthritis of the knee (non-arthroplasty). Rosemont (IL): American Academy of Orthopaedic Surgeons; 2008.
aag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008;59:762-784.