Monday, 24 Feb 2020

You are here

ACR-Arthritis Foundation Treatment Guidelines for Osteoarthritis

Today, the American College of Rheumatology (ACR), in partnership with the Arthritis Foundation (AF), released the 2019 ACR/AF Guideline for the Management of Osteoarthritis of the Hand, Hip and Knee. The ACR periodically updates guidelines to reflect any advances in management added to the literature since the last publication, which in this case was 2012.

Osteoarthritis (OA) is a common rheumatic disease that affects the entire joint, involving the cartilage, joint lining, ligaments, and bone. It is characterized by breakdown of the cartilage (the tissue that cushions the ends of the bones between joints), bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining (called the synovium). According to the Arthritis Foundation, approximately 27 million Americans suffer from the disease. Establishing effective management and treatment for OA is an ongoing goal in rheumatology.

“Patients with osteoarthritis can vary quite a bit in how the disease affects them. They might have a single joint, a few joints or many joints that are involved where symptoms can occur throughout adult life,” said Sharon Kolasinski, MD, a practicing rheumatologist who served as lead author for the guideline update. “The new guideline recognizes not only the variety of clinical presentations of OA, but also the broad array of treatment options available.  Clinicians and patients can choose from educational, behavioral, psychosocial, mind-body, physical and pharmacological approaches. It’s important to remember that treatment for OA is not one size fits all. Over time, various options might be used then reused or changed in response to a change in the patient’s symptoms.”

For the first time, the new guideline incorporates direct patient participation in its development. OA patients, who were recruited through a partnership with the Arthritis Foundation, were especially instrumental in emphasizing the role of shared decision making when choosing treatment options such as those with conditional recommendations.

“We are proud to have been involved in this work and to facilitate the important contributions of the patient and parent partners,” said Cindy McDaniel, Arthritis Foundation’s Senior Vice President of Consumer Affairs. “Their lived experiences truly helped to guide this project.”

Between the extensive literature review and patient insight, the updated guideline includes several differences since the 2012 recommendations. Of note, exercise remains an important intervention in the updated recommendations, with a strong body of literature supporting its use for almost all patients with OA. Below are other recommendations included in the update:

  • 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 NSAIDs 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 new strong recommendation against using hyaluronic acid injections in patients with hip OA.

Additionally, recommendations were 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. “A number of agents have been tested and fail to show adequate benefit to justify their use, while others will require additional investigations to clarify their place in the OA armamentarium,” said Dr. Kolasinski. “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 paper containing the full list of recommendations and supporting evidence is available at Clinical Practice Guidelines Osteoarthritis.

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

JAK Inhibitors Stimulate Osteoblasts

Science Translational Medicine has a report on how the use of Janus kinase (JAK) inhibitors may boost osteoblasts to battle bone erosions in conditions like rheumatoid arthritis (RA).

JAK inhibitors have been shown in clinical trials to retard the development of bone erosions while controlling RA inflammation and other clinical features.

Hormone Therapy for Postmenopausal Women

The NEJM weighs in on the problem of post-menopausal osteoporosis (OP) and tackles the use of hormonal therapy. The decline in estrogen after menopause may increase risks for osteoporosis, cardiovascular disease, and cognitive decline. The use of hormone replacement therapy (HRT) to obviate these issues may be primarily driven by hot flashes in postmenopausal women.1 Who may benefit from hormone therapy among postmenopausal women?

Knee Replacements Last 25 Years

UK registry reports that greater than 80% of total knee replacements can last for 25 years.

The outcomes regarding the duration and durability of knee arthroplasties is sketchy, with many orthopedists projecting a 15 to 20 year survivial. Hence the need for an appraisal of the data.

Should We Screen Younger Postmenopausal Women for Osteoporosis?

Do postmenopausal women, under age 65 years, need a baseline BMD testing? A JAMA Insights review suggests that the absolute risk of fracture is low in this group and that USPSTF guidelines should be considered - that we should be screening women younger than 65 years who are at increased risk of osteoporosis and we should be using a formal risk assessment tool to identify candidates for bone density testing.

Genicular Artery Embolization to Treat Osteoarthritis Knee Pain

A study from the Journal of Vascular and Interventional Radiology has shown that  knee pain secondary to osteoarthritis (OA) may be effectively treated by selective vascular interruption (embolization) showing efficacy and safety in a small pilot trial.