American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee

Authors

  • Marc C. Hochberg,

    Corresponding author
    1. University of Maryland School of Medicine, Baltimore
    • Division of Rheumatology, University of Maryland School of Medicine, 10 South Pine Street, MSTF 8-34, Baltimore, MD 21201
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    • Dr. Hochberg has received consultant fees (less than $10,000 each) from Abbott Laboratories, Amgen, AstraZeneca, Bayer Health Care, Bioiberica, Bristol-Myers Squibb, CombinatoRx, Covidien, Eli Lilly, Genentech, GlaxoSmithKline, Hoffman-La Roche, Merck, Merck Serono International, NicOx, Novartis, Pfizer, Pozen, Rand Corporation, Sanofi-Aventis, Smith & Nephew, Stryker Biotech, TransPharma Medical, and UCB, receives research support from the NIH, serves as a member/chair of the data safety monitoring boards for the National Eye Institute and Novartis, and serves on the medical advisory board for and owns stock in Theralogix.

  • Roy D. Altman,

    1. David Geffen School of Medicine, University of California, Los Angeles
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    • Dr. Altman has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Ferring, Rotta, Endo, Novartis, Lilly, and Smith & Nephew.

  • Karine Toupin April,

    1. University of Ottawa School of Medicine, Ottawa, Ontario, Canada
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  • Maria Benkhalti,

    1. University of Ottawa School of Medicine, Ottawa, Ontario, Canada
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  • Gordon Guyatt,

    1. McMaster University School of Medicine, Hamilton, Ontario, Canada
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  • Jessie McGowan,

    1. University of Ottawa School of Medicine, Ottawa, Ontario, Canada
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  • Tanveer Towheed,

    1. Queen's University School of Medicine, Kingston, Ontario, Canada
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    • Dr. Towheed has received speaking fees from and/or serves on the advisory board for Amgen, Novartis, Bristol-Myers Squibb, Hoffman-La Roche, and Schering (less than $10,000 each).

  • Vivian Welch,

    1. University of Ottawa School of Medicine, Ottawa, Ontario, Canada
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  • George Wells,

    1. University of Ottawa School of Medicine, Ottawa, Ontario, Canada
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  • Peter Tugwell

    1. University of Ottawa School of Medicine, Ottawa, Ontario, Canada
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    • Dr. Tugwell has received consultant fees (more than $10,000 each) from Abbott, Almirall, AstraZeneca, Aventis, Berlex, Biomatrix, Bristol-Myers Squibb, Caduceus Group, Centocor, Chelsea, Dimedix, Dimethaid, Eli Lilly, Glaxo-Welcome, GlaxoSmithKline, Hoechst Marion Roussel, Immunomedics, Innovus, Johnson & Johnson, Larvol, Lilly Research, Medicine Group, Medicus, Merck, Merck Frosst, Novartis, Novopharm, Ortho McNeil, Pennside, Pfizer, Roche, Sandoz, Scios, Searle, Teva Pharmaceuticals, UCB, and Wyeth Ayerst, and has received grant support from Aventis, Biomatrix, Cigna, Genzyme, IDRC, Merck, Novartis, Parke-Davis, Pfizer, Rhone-Poulenc, Sandoz, and Smithkline Beecham.


Abstract

Objective

To update the American College of Rheumatology (ACR) 2000 recommendations for hip and knee osteoarthritis (OA) and develop new recommendations for hand OA.

Methods

A list of pharmacologic and nonpharmacologic modalities commonly used to manage knee, hip, and hand OA as well as clinical scenarios representing patients with symptomatic hand, hip, and knee OA were generated. Systematic evidence-based literature reviews were conducted by a working group at the Institute of Population Health, University of Ottawa, and updated by ACR staff to include additions to bibliographic databases through December 31, 2010. The Grading of Recommendations Assessment, Development and Evaluation approach, a formal process to rate scientific evidence and to develop recommendations that are as evidence based as possible, was used by a Technical Expert Panel comprised of various stakeholders to formulate the recommendations for the use of nonpharmacologic and pharmacologic modalities for OA of the hand, hip, and knee.

Results

Both “strong” and “conditional” recommendations were made for OA management. Modalities conditionally recommended for the management of hand OA include instruction in joint protection techniques, provision of assistive devices, use of thermal modalities and trapeziometacarpal joint splints, and use of oral and topical nonsteroidal antiinflammatory drugs (NSAIDs), tramadol, and topical capsaicin. Nonpharmacologic modalities strongly recommended for the management of knee OA were aerobic, aquatic, and/or resistance exercises as well as weight loss for overweight patients. Nonpharmacologic modalities conditionally recommended for knee OA included medial wedge insoles for valgus knee OA, subtalar strapped lateral insoles for varus knee OA, medially directed patellar taping, manual therapy, walking aids, thermal agents, tai chi, self-management programs, and psychosocial interventions. Pharmacologic modalities conditionally recommended for the initial management of patients with knee OA included acetaminophen, oral and topical NSAIDs, tramadol, and intraarticular corticosteroid injections; intraarticular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy. Opioid analgesics were strongly recommended in patients who were either not willing to undergo or had contraindications for total joint arthroplasty after having failed medical therapy. Recommendations for hip OA were similar to those for the management of knee OA.

Conclusion

These recommendations are based on the consensus judgment of clinical experts from a wide range of disciplines, informed by available evidence, balancing the benefits and harms of both nonpharmacologic and pharmacologic modalities, and incorporating their preferences and values. It is hoped that these recommendations will be utilized by health care providers involved in the management of patients with OA.

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