The new 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip and Knee moves away from the concept of a hierarchical treatment pyramid to more of a focus on multimodal approaches that could be used in a combination throughout the life of a patient with osteoarthritis (OA).
“We need to think about for each individual what are the puzzle pieces that should go together to help manage their osteoarthritis,” said Tuhina Neogi, MD, PhD, FRCPC. “There’s no one size fits all for patients. You have to take into account individual patient factors to find the right combination for them.”
Dr. Neogi, a member of the team that formulated the guideline, discussed the guideline during the ACR/ARP Annual Meeting session 2019 ACR/AF Guideline for the Management of Osteoarthritis of the Hand, Knee and Hip on Wednesday, Nov. 13.
Sharon Kolasinski, MD, principal investigator for the guideline, discussed the process and guiding principles behind the formulation of the guideline. She also noted the differences between the 2019 draft guideline and the 2012 guideline. The new guideline recommendations will be available online in December and are expected to be published in print early next year.
The strong recommendation for exercise and weight loss continues, due to compelling evidence of efficacy along with the belief that the potential benefits clearly outweigh potential harms. The 2012 conditional recommendations for self-efficacy programs, tai chi, topical and oral NSAIDs, and intra-articular steroids have now been changed to strong recommendations based on new published data in the intervening time since the last guidelines.
Dr. Kolasinski said that those who worked on the 2019 guideline wanted to stress the large and impressive body of evidence in support of exercise in the treatment of arthritis.
“There’s really no hierarchy of one exercise being better than another, and we would emphasize it is most often more effective, particularly with its initiation in a supervised setting,” she said.
Transcutaneous electrical nerve stimulation now has a recommendation strongly against, due to high quality evidence regarding lack of efficacy for osteoarthritis in well-conducted studies; it had a conditional recommendation in 2012. There are also now strong recommendations against the use of glucosamine and chondroitin for knee and hip osteoarthritis, a change from conditional recommendations against both; this was because additional data in the intervening years provide high quality evidence regarding lack of efficacy. One exception was that of a conditional recommendation for the use of chondroitin in hand osteoarthritis based on a randomized trial that was well-conducted with low risk of bias and which demonstrated no safety concern.
In 2012, no recommendation for balance exercises or duloxetine was made, but the 2109 draft makes conditional recommendations for these therapies because of new data available in the intervening years. The 2012 conditional recommendation against topical capsaicin has been changed to a conditional recommendation for use because of new data. The 2019 guideline also has new conditional recommendations for using yoga, cognitive behavior therapy, radiofrequency ablation, and kinesio taping.
Dr. Neogi also stressed that the updated guideline doesn’t use the term “nonpharmacologic.” It’s an example of why those who work with patients with OA need to be mindful about the language used when discussing treatment options.
“‘Non-’something sounds like ‘nontreatment’ (to patients), and physical modalities, mind-body approaches, are really underutilized,” she said. “We have a lot of very good evidence for physical modalities such as exercise, weight loss, physical therapy, etc. We really need to change our language and change the way in which we approach these conversations with our patients so that they don’t feel that they are not getting a treatment when they’re receiving these recommendations.”