New knee osteoarthritis guidelines from Osteoarthritis Research Society International, an update of the group’s 2010 guidelines, recommend weight loss, education, exercise, and much more that’s familiar to practicing rheumatologists.
However, the group’s advice varies a bit from recent osteoarthritis (OA) guidelines separately issued by the American College of Rheumatology (ACR) and the American Academy of Orthopaedic Surgeons (AAOS).
For instance, the AAOS was neutral on acetaminophen and corticosteroid knee shots in its 2013 recommendations, citing a lack of evidence, but Osteoarthritis Research Society International (OARSI) guidelines recommend both in the absence of relevant comorbidities. Recent studies of steroid knee shots demonstrate "clinically significant short-term decreases in pain" that are "significantly greater" than are those with intra-articular hyaluronic acid, according to guidelines lead author Dr. Timothy McAlindon, chief of rheumatology at Tufts University in Boston, and his colleagues (Osteoarthritis Cartilage 2014 Jan. 23 [doi:10.1016/j.joca.2014.01.003]).
Meanwhile, hyaluronic acid knee injections provided greater long-term relief in another study, one of the findings that led OARSI, like the ACR, to suggest that the jury’s still out on hyaluronic acid. The AAOS rejected hyaluronic acid because of a lack of efficacy.
OARSI’s advice is based on recent literature and the expert opinion of its 13-member review panel; most members were rheumatologists and most were European. They voted on 13 nonpharmaceutical and 16 pharmaceutical treatments, deciding if they were appropriate, inappropriate, or – when evidence was scanty – of uncertain value for knee OA.
Treatments that made the cut as appropriate for all knee OA patients included biomechanical interventions, corticosteroid knee injections, land and water-based exercise, self-management and education, strength training, and weight management. Other treatments approved by the panelists included acetaminophen, warm soaks in mineral-rich water (balneotherapy), topical capsaicin, walking canes, duloxetine (Cymbalta), and NSAIDs when comorbidities don’t rule them out.
A variety of therapies fell into the "uncertain" category: acupuncture, avocado-soybean unsaponfiable supplements, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids, rose hip, transcutaneous electrical nerve stimulation, and therapeutic ultrasound. The group voted risedronate (Actonel) and neuromuscular electrical stimulation as inappropriate for knee OA because of a lack of evidence.
Newer findings have "increased safety concerns regarding use of treatments such as acetaminophen and opioids ... while evidence for use of treatments such as duloxetine, balneotherapy, and land-based exercises such as t’ai chi has strengthened," the authors noted.
OARSI reviewed biomechanical interventions more favorably than did the other groups, mostly because research now suggests that knee braces and foot orthoses improve function and decrease pain, stiffness, and drug use. Another trial supported wedged insoles as an alternative to valgus bracing.
Similar to the ACR guidelines but unlike stronger recommendations from the AAOS, OARSI also supported oral NSAIDs for most patients but was unsure about them when patients have heart disease and other relevant problems. The group recommended concomitant proton-pump inhibitors when gastric bleeding is a worry.
They noted that naproxen seems safer on the cardiovascular system than COX-2 inhibitors. Diclofenac appears to carry the highest risk for abnormal liver values, while celecoxib (Celebrex) seems to cause fewer ulcers but more cardiovascular problems. Topical NSAIDs work as well as oral formulations for OA knee pain, with fewer problems.
Unlike the ACR, the group also considered topical capsaicin "appropriate in patients without relevant comorbidities" and duloxetine "appropriate for most clinical subphenotypes," although adverse events – nausea, fatigue, and others – and the "availability of more targeted therapies predicated uncertain appropriateness for individuals with knee-only OA and comorbidities," they said.
OARSI funded the work, and is supported by companies promoting arthritis products. Most of the panelists have financial ties to Sanofi, Pfizer, Merck, Don-Joy, and other companies, but recused themselves when needed from voting.