Guidelines updated for managing hand, hip, knee osteoarthritis

New guidelines for management of hand, hip, and knee osteoarthritis (OA) were published in the April edition of Arthritis Care & Research.

The recommendations update the American College of Rheumatology’s (ACR) 2000 guidelines for hip and knee OA and provide new ones for hand OA. The recommendations are the result of a multidisciplinary Technical Expert Panel.

Nathan Wei, MD, with The Arthritis Treatment Center in Frederick, Md., said that hands were included in the guidelines because they are actually involved more often than previously thought.

"Knee and hip guidelines haven't really changed all that much primarily because we don't have any new approaches to treating OA," Wei said.

However, he noted that arthroscopy is no longer recommended for knee OA because of studies showing that it is no more effective than placebo.

The recommendations for pharmacologic interventions for knee and hip OA include acetaminophen; oral non-steroidal anti-inflammatory drugs (NSAIDs); tramadol, an opiate agonist; and intraarticular corticosteroid injections. The panel also recommends the use of topical NSAIDs for knee OA-especially by persons aged 65 and older.

Topical NSAIDs are being used more because of worries regardingcardiovascular risk with oral NSAIDs. "The problem is that some guidelinespropose using more opioid analgesics instead of NSAIDs," Wei said. "As a result we're seeing more falls in the elderly. The mortality rate from a fractured hip is much higher in the 65-and-older group than mortality from heart attack."

The new pharmacological recommendations for hand OA incorporate many of the same therapies, but also include topical capsaicin, COX-2 selective inhibitors and topical NSAIDs, such as trolamine salicylate.

Non-pharmacologic modalities for hip and knee OA are aerobic and aquatic exercise, losing weight if overweight, self-management programs, thermal agents, and manual therapy.

For hand OA, the panel recommends that patients should be seen by a medical professional to evaluate their ability to perform activities of daily living, to offer instruction on the use of joint protection techniques and thermal modalities, and to provide assistive devices and joint splints.

The recommendations-both “strong” and “conditional”-represent evidence-based and expert consensus-based suggestions that are intended to serve as a guide to healthcare providers in managing patients with symptomatic OA.

Unlike previous guidelines, these recommendations do not include a sequence of subsequent interventions when patients fail to respond adequately to initial therapies.