Osteoarthritis Guideline Updates Emphasize Shared Treatment Decision-Making

Updates to osteoarthritis guidelines emphasized the importance of shared decision-making between providers and patients when selecting treatment options.

The updates to the American College of Rheumatology and the Arthritis Foundation’s 2012 guideline for the treatment of osteoarthritis underwent peer review and reflect advances in management of the common rheumatic disease.

The recommendations, made by a voting panel of rheumatologists, an internist, physical and occupational therapists, and patients—for the first time ever—were based on evidence of benefit, safety, and tolerability of physical, educational, behavioral, psychosocial, mind-body, and pharmacologic interventions. Recommendations were meant to provide a variety of options for optimal management of osteoarthritis.

Exercise remained a strongly recommended and important intervention in the updated recommendations, as additional literature supported its use for almost all patients with osteoarthritis. An exercise program is more effective when patient preferences and access are considered, along with self-efficacy, self-management, and weight loss programs.

Strong recommendations were also made for weight loss in patients with hip or knee osteoarthritis. Tai chi, topical or oral NSAIDs, and intra-articular steroids were also strongly recommended for such patients.

Conditional recommendations made by the voting panel included balance exercises; yoga; cognitive behavioral therapy; kinesiotaping; orthoses for hand joints; patellofemoral bracing; acupuncture; thermal modalities; radiofrequency ablation; topical capsaicin; acetaminophen; duloxetine; and tramadol.

Strong recommendations were made against using bisphosphonates in patients with knee, hip, or hand osteoarthritis. Although there was 1 small study which suggested potential analgesic benefit in osteoarthritis, the data showed no improvement in pain or functional outcomes. Glucosamine; chondroitin sulfate; hydroxychloroquine; methotrexate; stem cell injections; platelet-rich plasma treatment; and tumor necrosis factor inhibitors and interleukin-1 receptor antagonists were also all strongly recommended against as treatment options for osteoarthritis.

A new strong recommendation was also made against using hyaluronic acid injection in patients with hip osteoarthritis and use of transcutaneous electric nerve stimulation for knee and hip osteoarthritis.

The voting panel also included a new conditional recommendation against using intraarticular hyaluronic acid injections in first carpometacarpal and knee osteoarthritis. Other conditional recommendations were made against use of fish oil; vitamin D; colchicine; intraarticular botulinum toxin injections; prolotherapy in patients with knee, hip, or hand osteoarthritis.

Although there are many options available for the treatment of osteoarthritis, some patients could continue experience symptom control or adverse effects from the interventions recommended.

Updating the guidelines highlighted the need for ongoing, appropriately funded, high-quality clinical research and the development of new treatment modalities to address the impact of the most common form of arthritis. Currently there are no phase 2 or 3 trials underway for disease-modifying agents for osteoarthritis.

Optimal management of osteoarthritis requires a comprehensive, multimodal approach. More research needs to be address and there is a need for more options with greater efficacy for patients with the condition.

The guideline, “2019 ACR/AF Guideline for the Management of Osteoarthritis of the Hand, Hip and Knee,” was published on the American College of Rheumatology website.