Another Perspective in Managing Osteoarthritis (ACR Guidelines 2000 for Hip and Knee OA)

“Physicians practicing (evidence-based medicine) will search for the highest evidence available, integrate this evidence with their clinical experience and judgment, and acknowledge the value judgments implicit in moving from evidence to action.”

These words from Guyatt are what probably drove the American College of Rheumatology to produce an update to their 1995 recommendations on the medical management of hip and knee OA. The goals for contemporary management of OA remains the same: control of pain, improvement of function and health-related quality of life and avoidance of the toxic effects of pharmacotherapy.

Their subcommittee aimed to review interim developments in the field and update the recommendations. Enumerated below are excerpts from the 2000 ACR guidelines.

  1. Patient education and, where appropriate, education of the patient’s family, friends and caregivers are integral parts of the treatment plan for patients with OA. Properly educated patients report decreased pain, decreased frequency of arthritis-related physician visits and improvements in physical function and over-all quality of life.

  2. Personalized social support via trained non-medical personnel (e.q. through periodic phone calls) have been shown to produce moderate-to-large degrees of improvement of pain and functional status of OA patients.

  3. Exercise programs to improve muscle strength, mobility and coordination in patients with OA have been shown to impact on pain and physical function and patients report less use of analgesics and fewer arthritis-related physician visits. Physical and occupational therapy play central roles in the management of patients with functional limitations.

  4. Weight loss should be advised to overweight and obese patients.

  5. Relief of mild-to-moderate pains can be afforded by paracetamol in many OA patients. But meta-analyses suggests greater improvements in both pain at rest, pain on motion and reduction of severe pain for NSAID-treated patients. Nevertheless, paracetamol should be tried as initial drug therapy based on its over-all costs, efficacy and safety.

  6. In patients with moderate to severe knee OA and in whom signs of inflammation are present, joint aspiration with intra-articular administration of steroids or a prescription of NSAIDs merits consideration as an alternate initial therapeutic approach.

  7. In patients who fail to obtain adequate symptomatic relief from paracetamol and/or NSAIDs, additional pharmacologic agents should be considered following evaluation of risk factors for serious upper GI and renal toxicity. Risk factors for serious upper GI bleeding include age>65 years, history of PUD or prior GI bleeding, concomitant use of steroids or anti-coagulants, presence of co-morbid conditions, and, possibly,  smoking and alcohol consumption. Risk factors for reversible renal failure in patients with intrinsic kidney disease (defined by serum Crea >2.0 mg/dl) include age >65 years, hypertension or heart failure, and concomitant use of diuretics and ACE Inhibitors.

  8. Additional pharmacologic agents to be considered include topical analgesics (metylsalicylate or capsaicin), topical NSAIDs, oral NSAIDs and COXIBs (for patients initially given paracetamol), IA steroids or hyaluronic acid, tramadol or more potent opioids (i.e. codeine or dextropropoxyphene).

  9. Although the efficacy of combination treatment has not been established in controlled trials, it is reasonable to use the recommended agents in combination in an individual patient. However, only a single NSAID should be used at any given time.

  10. Treatment of hip OA is similar to that of the knee save for the following: IA hyaluronan is not approved for hip OA; topical agents and IA steroids have not been studied for hip OA.

  11. Patients with severe symptomatic OA who fail to respond to medical therapy and who have progressive limitation of ADLs should be referred to an orthopedic surgeon for evaluation.

Compared to local guidelines, the ACR has recommendations on the use of exercise, physical/occupational therapy and personalized social support. Furthermore, NSAIDs/ COXIBs as initial therapy could be considered for those with moderate-severe OA and in those with evidence of inflammation. Additionally, combination treatment and indications for surgical consult were briefly discussed.

Another interesting part of the ACR 2000 was their statement regarding the duration of pharmacologic therapy for patients with OA.  They stated that:

“In all patients whose symptoms are well controlled, attempts should be made periodically to reduce the dosage of NSAID and/or analgesic agents and to determine whether it is possible to use such agents on an as-needed basis, rather than in a fixed dosing regimen.”

This statement implies that (1) treatment for OA is comparable to other chronic conditions like hypertension and diabetes wherein tapering of medications is attempted only once symptoms are well controlled, (2) regular physician visits should be advised to allow periodic evaluations to reduce medications, (3) duration of treatment may be long term for some patients particularly those whose symptoms are uncontrolled without maintenance meds, and (4) there are patients in whom medications may be given on an as-needed basis.

 Reference:

Altman R, Hochberg M, Moskowitz R, et al. Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. Ann Rheum Dis 2000.

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