Another change from the previous ACR recommendations for OA management is that the 2012 document does not recommend a sequence of subsequent interventions if initial therapies for OA do not result in an adequate response. This change is due to a lack of high-quality studies that reliably examined the benefit and safety of treatment modalities that could support recommendations of a specific sequence of therapy.
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According to Dr. Hochberg, nonpharmacologic and pharmacologic therapies were given “equal weighting” in panel deliberations and literature reviews for the 2012 recommendations. “The nondrug treatments were given a lot of attention because they are the cornerstone of the management approach to people with OA. We find [they are] often neglected in primary care because of the short amounts of time that providers have to interact with their patients,” he says.
Unlike the previous ACR recommendations, the 2012 document includes recommendations for management of symptomatic hand OA.
Dr. Hochberg highlighted some of the key points among the recommendations:
- Topical rather than oral nonsteroidal antiinflammatory drugs (NSAIDs) should be used whenever possible for people over age 75 years, a recommendation in accord with the American Geriatric Society.
- For hand OA, provision of assistive devices, use of thermal modalities and trapeziometacarpal joint splints, and use of oral and topical NSAIDs, tramadol, and topical capsaicin are conditionally recommended.
- Also for management of hand OA, it is conditionally recommended that intraarticular therapies and opioids not be used.
- Acetaminophen, recommended previously as initial therapy for knee and hip OA, is now only conditionally recommended among other pharmacologic agents, such as oral and topical NSAIDs, which can be used as initial therapy in patients with hip and knee OA.
- Aerobic, aquatic, resistance exercises, and weight loss are strongly recommended for knee and hip OA.
- For both knee and hip OA, nutraceuticals such as chondroitin sulfate, glucosamine, and topical capsaicin are conditionally recommended not to be used.
- Tai chi is conditionally recommended for knee OA, as is acupuncture in certain situations; no recommendation is given for tai chi for hip OA.
- Management is addressed for those patients who would normally be referred to orthopedic surgeons but who choose not to have a joint replacement or are not medically suitable for surgery.
Some of the recommendations may come as a surprise to rheumatologists, Dr. Hochberg predicts, including the recommendation related to topical therapy for knee OA for all age groups, and particularly for those over age 75. “I think most rheumatologists are not aware of it and have a feeling that it does not work as well as oral therapy,” he says, “However, the data from clinical trials indicate that it does work.”