2019 ACR/Arthritis Foundation Guidelines for Hand, Hip, and Knee Osteoarthritis Management

The American College of Rheumatology (ACR) and the Arthritis Foundation have released guidelines for the treatment of hand, hip, and knee osteoarthritis (OA). These guidelines, published in Arthritis Care & Research, provide recommendations for clinicians and for patients with OA and encourage the use of a shared decision-making model that accounts for patient preferences and values.

Investigators from both organizations followed the ACR guideline development process and the Grading of Recommendations, Assessment and Evaluation methodology to rate currently available evidence and develop the recommendations. They conducted an initial literature review through August 2018, providing a body of knowledge with which to work, followed by a systematic review of randomized controlled trials and certain selected observational studies.

Overall, the guideline authors suggested that a comprehensive plan for OA management is key. According to them, this plan may include “educational, behavioral, psychosocial, and physical interventions, as well as topical, oral, and intra-articular medications.” The applications of these interventions should be determined on an individual level, with some patients benefiting from 1 type of intervention at a time, and others benefiting from multiple interventions administered in sequence or in combination.

According to the researchers, treatment discussions should consider patients’ personal beliefs and preferences, as well as their current medical status. The guideline is applicable to patients with OA with “no specific contraindications to the recommended therapies.” Investigators cautioned that each patient should be assessed for medical conditions, including hypertension, cardiovascular disease, heart failure, gastrointestinal bleeding risk, and chronic kidney disease, along with other comorbidities that may result in increased risks for side effects with certain treatment modalities.

Investigators also noted that patients may experience a variety of additional symptoms resulting from the pain and functional limitations associated with OA and/or from their comorbidities. Assessing the broader effect of OA on these comorbidities is of particular importance when choosing treatment options and can be best managed through a multimodal treatment plan.

Finally, unless specified, the recommendations assume that patients will undertake the intervention in addition to usual care, which, for the purposes of this guideline, includes the use of maximally recommended or safely tolerated doses of over-the-counter oral nonsteroidal anti-inflammatory drugs (NSAIDs) and/or acetaminophen.

“Optimal management requires a comprehensive, multimodal approach to treating patients with hand, hip, and/or knee OA offered in the context of shared decision-making with patients, to choose the safest and most effective treatment possible,” the researchers noted. “A large research agenda remains to be addressed, with a need for more options with greater efficacy for the millions of people worldwide with [OA].”

The latest recommendations are outlined below.

Part 1: Physical, Psychosocial, and Mind-Body Approaches

Strong Recommendations:

• Exercise is strongly recommended for patients with knee, hip, and/or hand OA. Considerably more evidence exists supporting the use of exercise for knee and hip OA than hand OA; however, current evidence is insufficient to recommend a specific exercise prescription, and recommendations suggesting 1 type of exercise over another are largely based on expert opinion. Exercise recommendations should focus on patient preferences and access, both of which could act as barriers to participation. Although walking was the most common form of exercise evaluated in a majority of studies examining the role of aerobic exercise in OA management, a specific hierarchy of the various forms of exercise could not be identified from current literature. However, to provide the best benefit, physicians are recommended to provide advice to patients that is “as specific as possible.”

• Weight loss is strongly recommended for patients with knee and/or hip OA who are overweight or obese. Current evidence suggests that a loss of ≥5% of body weight may be associated with changes in clinical and mechanistic OA outcomes. These clinically important benefits will continue to increase with weight loss of 5% to 10%, 10% to 20%, and >20% of body weight.

• Self-efficacy and self-management programs are strongly recommended for patients with knee, hip, and/or hand OA. Despite generally small effect sizes, multiple studies have demonstrated consistent benefits resulting from participation in self-efficacy and self-management programs, with minimal risk. Recommended programs typically have used a multidisciplinary, group-based format that combine skill-building education related to OA and education about medication side effects, joint protection measures, and fitness and exercise goals.

• Tai chi is strongly recommended for patients with knee and/or hip OA. Tai chi, which combines meditation with “slow, gentle, graceful movements,” may provide holistic benefits in terms of strength, balance, and fall prevention, in addition to depression and self-efficacy.

• Cane use is strongly recommended for patients with knee and/or hip OA. Patients in whom in 1 or more joints causes a sufficiently large effect on ambulation, joint stability, or pain are recommended to use an assistive device.

• Tibiofemoral knee braces are strongly recommended for patients with knee OA. Patients in whom disease in either 1 or both knees causes a sufficiently large effect on ambulation, joint stability, and pain warrant the need for an assistive device. Patients must be able to tolerate the inconvenience and burden associated with bracing.

• Hand orthoses are strongly recommended for patients with first carpometacarpal (CMC) joint OA.

• Transcutaneous electrical stimulation (TENS) is strongly recommended against in patients with knee and/or hip OA. Studies examining TENS are of low quality with small sample sizes and variable controls.

Conditional Recommendations:

• Balance exercises are conditionally recommended for patients with knee and/or hip OA. These exercises improve patients’ ability to control and stabilize body position. To date, randomized controlled trials have not addressed the potential of balance-based exercises in reducing fall risk in patients with OA.

• Yoga is conditionally recommended for patients with knee OA. Yoga combines physical postures with breathing techniques and meditation or relaxation. Although the practice is less studied than tai chi, yoga may provide similar benefits for patients with OA.

• Cognitive behavioral therapy (CBT) is conditionally recommended for patients with knee, hip, and/or hand OA. A well-established body of literature supports the use of CBT for chronic pain conditions, with trials demonstrating improvements in pain, health-related quality of life, mood, fatigue, functional capacity, and disability. In OA, limited evidence suggests that CBT reduces pain; further research is needed to establish the benefits of CBT in OA.

• Patellofemoral braces are conditionally recommended for patients with patellofemoral knee OA. Patients in whom disease in either 1 or both knees is causing a sufficiently large effect on ambulation, joint stability, or pain may warrant the need for an assistive device. This recommendation is conditional due to variability in results across currently published literature. Physicians should keep in mind that some patients may have difficulty tolerating the inconvenience and burden of braces.

• Kinesiotaping is conditionally recommended for patients with knee and/or first CMC joint OA. This practice permits range of motion of the joint to which it is being applied, in contrast to braces. The evidence quality is limited owing to limitations in blinding when studying this practice.

• Hand orthoses are conditionally recommended for patients with OA in other joints of the hand. A wide variety of mechanical supports are currently available, including digital orthoses, ring splints, and rigid or neoprene orthoses. Insufficient data are available to recommend 1 type of orthoses over another. Patients considering hand orthoses may benefit from evaluation by an occupational therapist.

• Modified shoes are conditionally recommended against in patients with knee and/or hip OA. Although optimal footwear is of considerable importance for patients with OA, available studies do not define the best type of footwear to improve outcomes for either knee or hip OA.

• Lateral and medial wedged insoles are conditionally recommended against in patients with knee and/or hip OA. Currently available literature does not demonstrate a clear efficacy of lateral or medial wedged insoles.

• Acupuncture is conditionally recommended for patients with knee, hip, and/or hand OA. The efficacy of acupuncture remains a subject of controversy, due to issues with blinding, sham control validity, sample size, effect size, and prior expectations. The greatest number of positive trials with the largest effect sizes have been conducted in knee OA. Although the true magnitude of effect is unclear, the risk for harm is minor.

• Thermal interventions (locally applied heat or cold) are conditionally recommended for patients with knee, hip, and/or hand OA. The delivery method for thermal interventions varies considerably in published literature, and both the modality heterogeneity and short duration of benefit have led to a conditional recommendation.

• Paraffin, an additional method of heat therapy for the hands, is conditionally recommended for patients with hand OA.

• Radiofrequency ablation is conditionally recommended for patients with knee OA. This recommendation is conditional because of the heterogeneity of techniques and controls and lack of long-term safety data.

• Massage therapy is conditionally recommended against in patients with knee and/or hip OA. Studies of massage therapy have experienced high risk for bias, included small patient populations, and have not demonstrated OA-specific outcomes.

• Manual therapy with exercise is conditionally recommended against vs exercise alone in patients with knee and/or hip OA. A limited number of studies have assessed manual therapy in addition to exercise vs exercise alone. Limited data demonstrate additional benefit for exercise alone in OA symptom management.

• Iontophoresis is conditionally recommended against in patients with first CMC joint OA. Currently there are no published randomized controlled trials evaluating ionotophoresis for OA in any anatomic location.

• Pulsed vibration therapy is conditionally recommended against in patients with knee OA. Few trials have addressed this practice and therefore it has been conditionally recommended.

Part 2: Pharmacologic Management

Strong Recommendations:

• Topical NSAIDs are strongly recommended for patients with knee OA. Topical NSAIDs should be considered before the use of oral NSAIDs.

• Oral NSAIDs are strongly recommended for patients with knee, hip, and/or hand OA. Oral NSAIDs are the mainstay of pharmacologic OA management, with many trials establishing their short-term efficacy. Oral NSAIDs are the initial oral medication choice for OA, regardless of anatomic location, and are recommended vs all other available oral medications.

• Intra-articular glucocorticoid injections are strongly recommended for patients with knee and/or hip OA. Trials have demonstrated the short-term efficacy of intra-articular glucocorticoid injections.

• Ultrasound guidance for intra-articular glucocorticoid injection is strongly recommended for injection into hip joints. When available, ultrasound guidance may help ensure accurate drug delivery into the joint.

• Bisphosphonates are strongly recommended against in patients with knee, hip, and/or hand OA. A large amount of data show no improvement in pain or functional outcomes with bisphosphonate therapy.

• Glucosamine is strongly recommended against in patients with knee, hip, and/or hand OA. Despite multiple studies, there are discrepancies in efficacy reported by trials that are industry-sponsored vs publicly funded, raising serious concerns about publication bias. This recommendation represents a change from the prior conditional recommendation against glucosamine use.

• Chondroitin sulfate is strongly recommended against in patients with knee and/or hip OA as are combination products that include glucosamine and chondroitin sulfate.

• Hydroxychloroquine is strongly recommended against in patients with knee, hip, and hand OA. No efficacy has been demonstrated in multiple well-designed randomized controlled trials of patients with erosive hand OA.

• Methotrexate is strongly recommended against in patients with knee, hip, and/or hand OA. Well-designed randomized controlled trials have demonstrated no efficacy of methotrexate therapy.

• Intra-articular hyaluronic acid injections are strongly recommended against in patients with hip OA. Evidence about the lack of benefit of hyaluronic acid injections in hip OA is of higher quality.

• Platelet-rich plasma treatment is strongly recommended against in patients with knee and/or hip OA. There is concern surrounding the heterogeneity and lack of standardization in available preparations of platelet-rich plasma.

• Stem cell injections are strongly recommended against in patients with knee and/or hip OA. There is concern surrounding the heterogeneity and lack of standardization in available preparations of stem cell injections.

• Tumor necrosis factor inhibitors and interleukin-1 receptor antagonists are strongly recommended against in patients with knee, hip, and/or hand OA. Efficacy for these treatments has not been demonstrated and because of uknown toxicity risks, they are not recommended.

Conditional Recommendations:

• Topical NSAIDs are conditionally recommended for patients with hand OA. Topical NSAIDs should be considered before the use of oral NSAIDs. Practical considerations, such as frequent hand washing, have led to a conditional recommendation for topical NSAID use in hand OA.

• Topical capsaicin is conditionally recommended for patients with knee OA and conditionally recommended against in patients with hand OA. Topical capsaicin is conditionally recommended against in hand OA due to a potentially increased risk for contamination of the eye and lack of direct evidence to support use.

• Intra-articular glucocorticoid injections are conditionally recommended for patients with hand OA. This practice is conditionally recommended because of lack of evidence specific to this anatomic location.

• Intra-articular glucocorticoid injections vs other injections are conditionally recommended for patients with knee, hip, and/or hand OA. Intra-articular glucocorticoid injections are conditionally recommended vs other forms of intra-articular injection, including hyaluronic acid.

• Acetaminophen is conditionally recommended for patients with knee, hip, and/or hand OA. Effect sizes in clinical trials for acetaminophen are very small, and longer-term treatment has been found to be as effective as placebo. Acetaminophen may be appropriate for patients in whom NSAIDs are contraindicated.

• Duloxetine is conditionally recommended for patients with knee, hip, and/or hand OA. Duloxetine may have treatment efficacy when used either alone or in combination with NSAIDs, although physicians should be aware of issues regarding tolerability and side effects.

• Tramadol is conditionally recommended for patients with knee, hip, and/or OA. In certain circumstances, tramadol or other opioids may be appropriate in the treatment of OA, including patients in whom NSAIDs are contraindicated.

• Non-tramadol opioids are conditionally recommended against in patients with knee, hand, and/or hip OA with the recognition that they may be used under certain circumstances, particularly when alternatives have been exhausted. Very modest benefits for long-term opioid benefit have been noted, in addition to a high risk for toxicity and dependence. The lowest possible dose should be used for the shortest length of time, if necessary.

• Colchicine is conditionally recommended against in patients with knee, hip, and/or hand OA. Two very small studies that suggested an analgesic benefit of colchicine in OA contained low-quality data. Potential adverse effects and drug interactions may occur with colchicine use.

• Fish oil is conditionally recommended against in patients with knee, hip, and/or hand OA. Despite its popularity as a dietary supplement, only 1 published trial has addressed the role of fish oil in OA; researchers of this study failed to demonstrate efficacy of a higher dose vs lower dose of fish oil.

• Vitamin D is conditionally recommended against in patients with knee, hip, and/or hand OA. Limited and questionable health benefits have been associated with vitamin D supplementation.

• Chondroitin sulfate is conditionally recommended for patients with hand OA. A single trial has suggested analgesic efficacy of chondroitin sulfate without evidence of harm in hand OA.

• Intra-articular hyaluronic acid injections are conditionally recommended against in patients with knee and/or first CMC joint OA. Although apparent benefits of hyaluronic acid injections have been reported, these reviews did not consider the risk for bias across individual primary studies. This conditional recommendation is against consistent use of hyaluronic acid injections.

• Intra-articular botulinum toxin injections are conditionally recommended against in patients with knee and/or hip OA. A small number of trials in knee or hip OA have suggested a lack of efficacy of intra-articular botulinum toxin treatment, and no trials have evaluated this treatment in hand OA.

• Prolotherapy is conditionally recommended against in patients with knee and/or hip OA. Only a limited number of trials with a small number of participants have demonstrated small effect sizes in knee or hip OA.

Reference

Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee [published online January 6, 2020]. Arthritis Care Res. doi:10.1002/acr.24131