ACR Updates Osteoarthritis Guidance Save

New evidence-based recommendations emphasize exercise, self-management, appropriate weight loss, and shared decision-making; introduce conditional recommendations for GLP-1 receptor agonists in knee osteoarthritis and methotrexate in erosive hand osteoarthritis

The American College of Rheumatology (ACR) has released updated clinical guidance for the treatment and management of osteoarthritis (OA) of the knee, hip, and hand. The evidence-based recommendations update the 2019 ACR/Arthritis Foundation guideline and are designed to support individualized, shared decision-making between patients and clinicians.

Osteoarthritis is the most common form of arthritis, affecting an estimated 33 million people in the United States and more than 600 million people worldwide. It can cause joint pain, stiffness, swelling, loss of function, sleep disruption, reduced quality of life, and limitations in work and independent living.

The updated guidance emphasizes that OA treatment should be comprehensive and tailored to each person’s symptoms, goals, medical history, access to care, and preferences. The recommendations underscore the importance of beginning with interventions that have the lowest potential toxicity and combining behavioral, physical, and pharmacologic approaches when appropriate.

“These updated recommendations recognize that there is no single treatment pathway that fits every person living with osteoarthritis,” said Sharon L. Kolasinski, MD, principal investigator at the Perelman School of Medicine, University of Pennsylvania. “Our strongest recommendations continue to center on helping people build confidence in managing their condition, remaining physically active, and pursuing weight loss when appropriate. At the same time, the new evidence gives clinicians and patients additional options to discuss, in carefully selected situations.”

Key Recommendations

The ACR’s strong recommendations highlight interventions that should form the foundation of OA management for many patients, including:

• Enhancing self-efficacy and self-management.
• Participating in exercise.
• Pursuing weight loss when appropriate.
• Using topical and oral nonsteroidal anti-inflammatory drugs (NSAIDs), when clinically appropriate.
• Considering intraarticular glucocorticoid injections.

The guidance also includes conditional recommendations for selected biomechanical, mind-body, physical, and pharmacologic treatments. Conditional recommendations indicate that a therapy may be appropriate for many patients but should be considered through an individualized conversation about expected benefits, potential harms, treatment burden, comorbidities, affordability, access, and personal values.

New Recommendations

The update introduces two notable conditional recommendations:

• GLP-1 receptor agonists may be considered to help people with knee OA achieve an optimal weight when clinically appropriate.
• Methotrexate may be considered for people with erosive hand OA.

The guideline panel also made additional strong and conditional recommendations against a range of injectable and oral therapies where the available evidence did not support their use or where potential harms, costs, or other concerns outweighed anticipated benefits.

“The addition of conditional recommendations for GLP-1 receptor agonists and methotrexate reflects an evolving evidence base and the need to address distinct clinical circumstances,” said Dr. Kolasinski. “A conditional recommendation is not a one-size-fits-all directive. It is an invitation to have a thoughtful, informed conversation about whether a treatment fits an individual patient’s condition, priorities, and overall health.”

Patient-Centered Care Remains Central

The ACR emphasizes that its recommendations are intended to inform—not replace—clinical judgment and patient choice. They should not be used to limit or deny access to therapies.

Treatment decisions should account for OA severity, pain and functional limitations, other health conditions, prior surgery, medication risks, transportation and financial barriers, insurance coverage, and the patient’s ability to participate in care. Many people may benefit from a multidisciplinary approach involving primary care clinicians, rheumatologists, physical therapists, occupational therapists, orthopedic surgeons, and other members of the care team.