In the draft of the American College of Rheumatology’s updated treatment guideline for hip, knee, and hand osteoarthritis (OA) – previewed at the 2019 ACR/ARP Annual Meeting in Atlanta – exercise remains an important intervention, with a strong body of literature supporting its use for almost all patients with OA.
Sharon L. Kolasinski, MD, a rheumatologist from the University of Pennsylvania who served as lead author for the guideline update, said that the new guideline, “emphasizes a comprehensive approach to the management of osteoarthritis rather than a stepwise algorithm.
“The clinician and the patient are invited to choose from a varied list of interventions (educational, behavioral, psychosocial, mind-body, physical and pharmacological approaches) that might be used and reused over time to address the pain and functional compromise caused by osteoarthritis.”
Clinicians can expect to see several differences between the new recommendations and the guideline published in 2012, including:
- Strong recommendations (previously conditional) for self-efficacy/self-management programs, use of tai chi for knee and hip OA, topical NSAIDs for knee and hand OA, oral non-steroidal anti-inflammatory drugs and intra-articular steroids for knee and hip OA.
- A new conditional recommendation for balance exercises for knee and hip OA and duloxetine for knee OA.
- A conditional recommendation for using topical capsaicin in patients with knee OA (previously conditional against).
- New conditional recommendations for using yoga, cognitive behavioral therapy, radiofrequency ablation and kinesiotaping for first carpometacarpal and knee OA.
- A conditional recommendation against using manual therapy with exercise for knee and hip OA (previously was conditionally for usage).
- A strong recommendation against transcutaneous electric nerve stimulation for knee and hip OA (previously was a conditional recommendation).
- A new conditional recommendation against using intra-articular hyaluronic acid injections in first carpometacarpal and knee OA.
- A strong recommendation against using glucosamine, and for using chondroitin, in patients with knee and hip OA (previously were conditional recommendations).
A notable addition to the updated guideline is a new strong recommendation against using hyaluronic acid injection in patients with hip OA. No recommendation regarding the use of hyaluronic acid injections in the hip was specified in 2012.
“In the current revision, hyaluronic acid injections for first carpometacarpal and knee OA were conditionally recommended against and hyaluronic acid injection for hip OA was strongly recommended against,” Dr. Kolasinski said. “These recommendations were made based on our meta-analysis which indicated that, when high quality studies are evaluated, hyaluronic acid injections are not superior to saline injections.
It was also recognized that contextual effects could play a role in reported benefits in studies with a greater risk of bias. While clinicians may consider hyaluronic acid injections for patients who have failed multiple alternative interventions and have limited alternative options, the decision to choose hyaluronic acid injections requires shared decision making between the patient and the clinician that weighs the risks and benefits relevant to the individual patient.”
Recommendations were also made against the use of bisphosphonates, hydroxychloroquine, methotrexate, PRP injections (in hip and knee OA), stem cell injections (in hip and knee OA), tumor necrosis factor inhibitors and interleukin-1 receptor antagonists.
The guideline team found that several agents had been tested since the last update and had failed to show adequate benefit to justify their use, while others will require additional investigations to clarify their place in the OA armamentarium. The recommendations against usage of these therapies reflects the fact that pharmacologic options remain limited for the management of OA. A broad suggested research agenda is outlined in the guideline to address this gap.
The manuscript containing the full list of recommendations and supporting evidence is currently under peer review and is scheduled to be published by early 2020.