Proposed 2011 American College of Rheumatology Recommendations for the Use of Non-pharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip and Knee

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The American College of Rheumatology (ACR) last published recommendations for the management of hip and knee osteoarthritis (OA) in 2000. This project updated the recommendations for hip and knee OA and developed new recommendations for hand OA. A list of pharmacological and non-pharmacological 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. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) 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 (TEP) comprised of various stakeholders to formulate the recommendations for use of non-pharmacologic and pharmacologic modalities for OA of the hand, hip and knee. Modalities ‘suggested’ 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 non-steroidal anti-inflammatory drugs (NSAIDs), tramadol, topical capsaicin. Non-pharmacologic modalities ‘recommended’ for the management of knee OA were aerobic, aquatic and/or resistance exercises as well as weight loss for overweight patients. Non-pharmacologic modalities ‘suggested’ for knee OA included self-management programs, psychosocial interventions, Tai Chi, medial wedge insoles for valgus knee OA, subtalar strapped lateral insoles for varus knee OA, medially-directed patellar taping, manual therapy, walking aids and thermal modalities. Pharmacologic modalities ‘suggested’ for patients with knee OA included acetaminophen, oral and topical NSAIDs, tramadol, intra-articular corticosteroid and hyaluronate injections; opioids are ‘recommended’ for patients who are either not willing to undergo or have contraindications for total joint arthroplasty after having failed medical therapy, Separate recommendations could not be made for hip OA because of limited scientific evidence. These draft 2011 American College of Rheumatology recommendations for the management of patients with hand, hip and knee OA are based on the best available evidence of benefit and safety of both non-pharmacologic and pharmacologic interventions informing the consensus judgment of clinical experts from a wide range of disciplines balancing the benefits and harms of these treatments and incorporating their preferences and values. It is hoped that these recommendations will be utilized by primary care providers in the management of their patients with osteoarthritis.