Hand, knee and hip osteoarthritis recommendations updated

Revised recommendations aimed at improving the treatment of patients with osteoarthritis (OA) of the hand, hip and knee were published by the American College of Rheumatology on March 27. They appear on the organization's website and in the April Arthritis Care & Research.

The revised recommendations are based on a systematic review of current evidence, coupled with the input of an expert panel. The specific recommendations were developed based on the quality of available evidence and an assessment of the balance of potential benefits and harms, and are reported in a manner intended to facilitate shared decision making that factors in the values and judgments of both patients and practitioners. Interventions with a “strong” recommendation are those it is believed that most informed patients would choose to pursue for treatment, while “conditional” recommendations are those it is believed a majority of informed patients would choose to pursue, but some would not, based on their preferences.

For hand OA, nonpharmacologic conditional recommendations are as follows:

• Evaluate the ability to perform activities of daily living;
• Instruct in joint protection techniques;
• Provide assistive devices, as needed, to help patients perform daily living activities;
• Instruct in use of thermal modalities; and
• Provide splints for patients with trapeziometacarpal joint OA.

Pharmacologic conditional recommendations are as follows:

• Use topical capsaicin; topical nonsteroidal anti-inflammatory drugs (NSAIDs), including trolamine salicylate; oral NSAIDs, including COX-2 selective inhibitors; and tramadol;
• Do not use intraarticular therapies or opioid analgesics; and
• Use topical rather than oral NSAIDs in patients age 75 years and older. For those younger than 75 years, there is no preference for using topical rather than oral NSAIDs.

For knee OA, cardiovascular (aerobic) and/or resistance land-based or aquatic exercise, as well as weight loss in overweight patients, is strongly recommended. Conditional recommendations for patients include the following:

• Participate in self-management programs;
• Receive manual therapy in combination with supervised exercise;
• Receive psychosocial interventions;
• Use medially directed patellar taping;
• Wear medially wedged insoles if patients have lateral compartment OA;
• Wear laterally wedged subtalar strapped insoles if patients have medial compartment OA;
• Learn to use thermal agents;
• Receive walking aids, as needed;
• Do tai chi; and
• Receive traditional Chinese acupuncture or be instructed in the use of transcutaneous electrical stimulation only if they are a knee replacement candidate who is unwilling or unable to undergo the procedure.

There are no recommendations for participating in balance exercises, wearing laterally wedged insoles, receiving manual therapy alone, wearing knee braces, or using laterally directed patellar taping.

It is conditionally recommended that patients with knee OA use acetaminophen, oral NSAIDs, topical NSAIDs, tramadol or intra-articular corticosteroid injections; that chondroitin sulfate, glucosamine and topical capsaicin should not be used; and that opioid analgesics should be reserved for patients who have an indication for total joint replacement but are either unwilling to or unable to undergo the procedure.

For hip OA, it is strongly recommended that patients should participate in aerobic and/or resistance exercise, aquatic exercise and lose weight, if overweight. Self-management programs and patient education and manual therapy in combination with supervised exercise are conditionally recommended. No recommendations were made for balance exercises, either alone or in combination with strengthening exercises, tai chi or receiving manual therapy alone.

It is conditionally recommended that patients with hip OA use acetaminophen, oral NSAIDs, tramadol or intra-articular corticosteroid injections but not use chondroitin sulfate and glucosamine. Opioid analgesics should be reserved for patients who have an indication for total joint replacement but are either unwilling to undergo or have contraindications to undergoing the procedure.

The update is the first in a decade and includes new recommendations for hand OA.