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, psycho-social, 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. Their lived experiences truly helped to guide this project."
Cindy McDaniel, Arthritis Foundation's Senior Vice President of Consumer Affairs
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 https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Osteoarthritis.