2012 ACR Recommendations for Common Forms of OA

The American College of Rheumatology (ACR) had come out with recommendations on the management of knee and hip osteoarthritis (OA) way back in 2000. It was the European League Against Rheumatism (EULAR) which came out with guidelines for hand OA in 2007. Since then, other groups, such as the Osteoarthritis Research Society International (OARSI) and American Academy of Orthopedic Surgeons (AAOS), have followed suit in reviewing the evidence on how best to manage osteoarthritis. It is important to note, that treatment which work for a particular form of OA, does not necessarily apply to others. The new recommendations not only reflect additional data provided by newer studies but also changes in the manner by which guidelines are developed. And as such, we do expect some dramatic changes in the recommendations.

Fortunately, this iteration of ACR Guidelines cover the more common forms of OA involving the hands, knees and hips.
HAND OSTEOARTHRITIS
Like before, there are still few high-quality studies on interventions for hand OA published in peer-reviewed journals. Therefore, no strong recommendations were made for this condition. Instead, the ACR conditionally recommends the following:
  • All patients with hand OA should be evaluated in their ability to perform activities of daily living (ADL)
  • Patients should be instructed of joint protection techniques and evaluated if they would need assistive devices as aids in performing ADLs
  • Patients should be taught how to use thermal modalities for managing symptoms
  • Should there be trapeziometacarpal joint involvement, providing finger splints may be helpful
  • Pharmacologic management may be in the form of either topical or oral NSAIDs, topical capsaicin or tramadol
  • For patients with hand OA >75 years of age, topical NSAIDs are preferred over oral NSAIDs. No preference was stated for patients <75 years of age.
The following interventions should not be used:
  • Intra-articular steroid and hyaluronic injections
  • Opioid analgesics
  • Oral methotrexate and sulfasalazine (in the setting of erosive or inflammatory hand osteoarthritis)
KNEE OSTEOARTHRITIS
The guidelines strongly recommend the following non-pharmacologic interventions:
  • All patients should be enrolled in an exercise program – with no preference between aquatic and land-based exercise and should involve aerobic and/or resistance training.
  • All overweight patients should be advised about weight loss.
The following non-pharmacologic interventions are conditionally recommended:
  • Self-management programs with or without psychosocial intervention
  • Thermal agents and manual therapy (as done by PTs)
  • Medially directed patellar taping
  • Tai-chi programs
  • Walking aids/ assistive devices
  • Wedge insoles for compartmental knee OA
  • For patients with moderate to severe knee OA who are candidates for arthroplasty but unwilling to undergo such, traditional Chinese acupuncture and TENS may be tried
For patients failing to obtain adequate relief from intermittent dosing of analgesics and NSAIDs, the physician may use any of the following:
  • Acetaminophen
  • Oral or topical NSAIDs
  • Tramadol
  • Intra-articular steroids
The following are not recommended to be used in knee OA:
  • Nutritional supplements (glucosamine, chondrotin)
  • Topical capsaicin
Like in hand OA, the guidelines indicate that for patients >75 years of age, topical rather than oral NSAIDs are preferred. Other options that may be tried include duloxetine, tramadol or intra-articular hyaluronan.
If a patient has a history of symptomatic or complicated upper GI bleed but has not had a bleed in the past year and the physician opts to use an NSAID, either a COX-2 selective inhibitor (COXIB) or a non-selective NSAID in combination with a proton pump inhibitor be used. But if the patient has had an upper GI bleed in the past year, COXIBs may still be given in combination with a proton pump inhibitor for knee OA.
If a patient is on ASA <325mg/d for cardiac protection and the practitioner opts to use an NSAID, the guidelines strongly recommend using an NSAID other than ibuprofen.
Oral NSAIDs (and COXIBs) should not be used in patients with chronic kidney disease stage IV or V (with GFR <30ml/min). The use of NSAIDs in patients with CKD III should be made on an individual basis after considering both risks and benefits.
For knee OA patients who fail to adequately respond to both pharmacologic and non-pharmacologic interventions and are either unwilling to undergo arthroplasty or are not candidates for surgery, the guidelines strongly recommend the use of opioid analgesics and conditionally recommends the use of duloxetine.
HIP OSTEOARTHRITIS
For all patients with hip osteoarthritis, the guidelines strongly recommend:
  • Enrolment in an exercise program – with no preference whether land- or aquatic-based
  • Overweight patients be counseled about weight loss
Furthermore, the following non-pharmacologic interventions are conditionally recommended for use in patients with hip OA
  • Self-management programs
  • Thermal and manual therapies (as done by PTs)
  • Walking aids (such as canes)
Unlike knee OA, there is no data on the use of other non-pharmacologic interventions in hip OA (patellar taping, insoles, acupuncture, TENS, tai chi).
Pharmacologic interventions for hip OA include:
  • Paracetamol
  • Oral NSAIDs
  • Tramadol
  • Intra-articular steroid injections
No recommendations could be made regarding the use of topical NSAIDs, topical capsaicin, intra-articular hyaluronates, duloxetine and opioid analgesics due to lack of data.
 
Reference: Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 Guidelines for the use of Non-pharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip and knee. Arth Care and Res April 2012; 64 (4): 465-474.
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