These recommendations represent a change from the prior conditional recommendation against the use of glucosamine. Duloxetine is conditionally recommended for patients with knee, hip, and/or hand OA. Prolotherapy is conditionally recommended against in patients with knee and/or hip OA. Acetaminophen is conditionally recommended for patients with knee, hip, and/or hand OA. Use of Herbal Medications for Treatment of Osteoarthritis and Rheumatoid Arthritis. The menisci and articular cartilage: a life-long fascination. Using GRADE, a recommendation can be either in favor of or against the proposed intervention and either strong or conditional 10, 11. When available, ultrasound guidance for steroid injection may help ensure accurate drug delivery into the joint, but is not required for knee and hand joints. For those with limited pharmacologic options due to intolerance of or contraindications to the use of NSAIDs, acetaminophen may be appropriate for short‐term and episodic use. Specifically, knee osteoarthritis (OA) accounts for a large burden of MSK disability worldwide. Members of the Ad Hoc Committee on OA Guidelines followed an evidence-based medicine approach to revise the guidelines by reviewing an extensive literature search of the Cochrane and Medline databases and … This treatment has not been evaluated in hand OA and, therefore, no recommendation is made with regard to OA of the hand. Trials have demonstrated improvement in pain, health‐related quality of life, negative mood, fatigue, functional capacity, and disability in conditions other than OA. Guidelines and recommendations are intended to promote beneficial or desirable outcomes, but cannot guarantee any specific outcome. Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for patterns of practice and not to dictate the care of a particular patient. Neuromuscular training has been developed to address muscle weakness, reduced sensorimotor control, and functional instability specifically seen with knee OA, with a series of dynamic maneuvers of increased complexity. Pharmaceutical‐grade preparations of glucosamine are available and have been studied in multiple trials. While a variety of centrally acting agents (e.g., pregabalin, gabapentin, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and tricyclic antidepressants) have been used in the management of chronic pain, only duloxetine has adequate evidence on which to base recommendations for use in OA. The quality of the EULAR recommendations for the management of hip and knee osteoarthritis (OA) was evaluated using a validated instrument. Figure 2 summarizes the approaches that were not recommended. Trials of intraarticular glucocorticoid injections have demonstrated short‐term efficacy in knee OA. Dr. Neogi has received consulting fees from Pfizer, Regeneron, EMD Merck Serono, and Novartis (less than $10,000 each). This guideline included an initial literature review limited to English‐language publications from inception of the databases to October 15, 2017, with updated searches conducted on August 1, 2018 and relevant papers included. Cane use is strongly recommended for patients with knee and/or hip OA in whom disease in 1 or more joints is causing a sufficiently large impact on ambulation, joint stability, or pain to warrant use of an assistive device. We thank Nancy Baker, ScD, MPH, OTR/l, Yvonne Golightly, PT, MS, PhD, Thomas Schnitzer, MD, PhD, and ChenChen Wang, MD, MSc for serving (along with authors Joel Block, MD, Leigh Callahan, PhD, Carole Dodge, OT, CHT, David Felson, MD, MPH, William F. Harvey, MD, MSc, Edward Herzig, MD, Marc C. Hochberg, MD, MPH, Sharon L. Kolasinski, MD, C. Kent Kwoh, MD, Amanda E. Nelson, MD, Tuhina Neogi, MD, PhD, Carol Oatis, PT, PhD, Jonathan Samuels, MD, Daniel White, PT, ScD, and Barton Wise, MD, PhD) on the Expert Panel. A large research agenda remains to be addressed, with a need for more options with greater efficacy for the millions of people worldwide with osteoarthritis. Physiotherapists may improve management of knee osteoarthritis through greater psychosocial focus, being proactive with advice, and offering longer-term reviews: a qualitative study. Symptomatic Efficacy of Pharmacological Treatments for Knee Osteoarthritis: A Systematic Review and a Network Meta-Analysis with a 6-Month Time Horizon. Intentional weight loss in overweight and obese patients with knee osteoarthritis: is more better? Systematic reviews of observational studies published by others were included if, in the opinion of the Voting Panel, they added critical information for the formulation of a recommendation: for example, related to adverse effects that may not be seen in shorter‐duration RCTs. Stem cell injections are strongly recommended against in patients with knee and/or hip OA. Colchicine is conditionally recommended against in patients with knee, hip, and/or hand OA. Practical considerations (e.g., frequent hand washing) and the lack of direct evidence of efficacy in the hand lead to a conditional recommendation for use of topical NSAIDs in hand OA. However, clinical trials of exercise for OA include patients with pain and functional limitations due to OA, and improvements in OA‐specific outcomes have been demonstrated; thus, results are likely to be generalizable to most patients with pain due to OA. It is assumed that such an assessment will be performed prior to finalization of an individual treatment plan. The weight of the evidence indicates a lack of efficacy and large placebo effects. Positive trials and meta‐analyses have also been published in a variety of other painful conditions and have indicated that acupuncture is effective for analgesia. However, based on the available evidence regarding OA specifically, a conditional recommendation against the use of massage for reduction of OA symptoms is made, though the Voting Panel acknowledged that massage may have other benefits. Massage therapy is conditionally recommended against in patients with knee and/or hip OA. An overview of a general approach to management of OA is outlined in Figure 1 for recommended options, but no specific hierarchy of one option over another is implied other than on the basis of strength of the recommendation. They also tend to be more effective when combined with self‐efficacy and self‐management interventions or weight loss programs. 1 As opposed to its 2012 recommendations, 4 this update was developed from an internal systematic review of randomized controlled trials (RCTs). International Journal of Environmental Research and Public Health. Topical capsaicin is conditionally recommended for patients with knee OA and conditionally recommended against in patients with hand OA. However, she believes that in the meantime, “there are many other areas of research that really would be fruitful to help our patients more immediately.”. If an opioid is being considered, tramadol is conditionally recommended over non‐tramadol opioids. Recent work has highlighted the very modest level of beneficial effects in the long‐term (3 months to 1 year) management of non‐cancer pain with opioids 30. Evidence-Based Complementary and Alternative Medicine. Dr. Hochberg has received consulting fees, speaking fees, and/or honoraria from Bone Therapeutics, Bristol‐Myers Squibb, EMD Serono, IBSA, and Theralogix LLC (less than $10,000 each) and from Eli Lilly, Novartis Pharma AG, Pfizer, and Samumed LLC (more than $10,000 each), royalties from Wolters Kluwer for UpToDate, owns stock or stock options in BriOri BioTech and Theralogix LLC, and is President of Rheumcon, Inc. Dr. Block has received consulting fees, speaking fees, and/or honoraria from Zynerba Pharma, GlaxoSmithKline, and Medivir (less than $10,000 each) and royalties from Agios, GlaxoSmithKline, Omeros, and Daiichi Sankyo for human chondrosarcoma cell lines. Going from evidence to recommendations: the significance and presentation of recommendations, GRADE guidelines: 15. The delivery of instruction by physical and occupational therapists is helpful, and often essential, for the appropriate initiation and maintenance of exercise as a part of OA management. In addition, gloves may offer benefit by providing warmth and compression to the joints of the hand. Spa therapy with physical rehabilitation is an alternative to usual spa therapy protocol in symptomatic knee osteoarthritis. The Voting Panel made conditional recommendations when the quality of the evidence proved low or very low and/or the balance of benefits versus harms and burdens was sufficiently close that shared decision‐making between the patient and the clinician would be particularly important. A small subset of patients treated with these agents had rapid joint destruction leading to early joint replacement. Evidence suggests that duloxetine has efficacy in the treatment of OA when used alone or in combination with NSAIDs; however, there are issues regarding tolerability and side effects. This guideline covers assessing and managing osteoarthritis in adults. … For the purposes of this guideline, usual care includes the use of maximally recommended or safely tolerated doses of over‐the counter oral nonsteroidal antiinflammatory drugs (NSAIDs) and/or acetaminophen, as has generally been explicitly permitted in clinical trials of nonpharmacologic interventions. Keeping you informed. Further research is needed to establish whether or not benefits in OA are related to alteration in mood, sleep, coping, or other factors that may co‐occur with, result from, or be a part of the experience of OA 22. Acupuncture is conditionally recommended for patients with knee, hip, and/or hand OA. These include establishing “what the optimal exercise prescription is for any given patient,” and which biomechanical aids and types of support could be helpful. Dr. Kwoh has received consulting fees, speaking fees, and/or honoraria from Astellas, Fidia, GlaxoSmithKline, Kolon TissueGene, Regeneron, Regulus, Taiwan Liposome Company, and Thusane (less than 10,000 each) and from EMD Serono, and Express Scripts (more than $10,000 each). Osteoarthritis Year in Review 2020: Epidemiology & Therapy. Briefly, this work involved 5 teams: 1) a Core Leadership Team that supervised and coordinated the project and drafted the clinical/population, intervention, comparator, outcomes (PICO) questions that served as the basis for the evidence report and manuscript; 2) a Literature Review Team that completed the literature screening and data abstraction and produced the Evidence Report (Supplementary Appendix 2, http://onlin;elibr;ary.wiley.com/doi/10.1002/art.41142/;abstract); 3) an Expert Panel that had input into scoping and clinical/PICO question development; 4) a Patient Panel; and 5) an interprofessional Voting Panel that included rheumatologists, an internist, physical and occupational therapists, and patients (Supplementary Appendix 3, http://onlin;elibr;ary.wiley.com/doi/10.1002/art.41142/;abstract). The full text of this article hosted at iucr.org is unavailable due to technical difficulties. Recommendations assume appropriate application of physical, psychological, and/or pharmacologic therapies by an appropriate provider. We focused on management options that are available in the US and, for pharmacologic therapies, we additionally focused on agents that are available in pharmaceutical‐grade formulations, thus eliminating most nutraceuticals. Nonpharmacological and nonsurgical approaches in OA. Pulsed vibration therapy is conditionally recommended against in patients with knee OA. ACR Guidelines. A limited number of trials involving a small number of participants have shown small effect sizes of prolotherapy in knee or hip OA. This is an update on 2012 guidelines in which direct patient participation has been incorporated for the first time. Development of more effective therapies that permit a sophisticated and individualized approach to the patient with OA await the outcome of future investigation. As well as the strong focus on exercise in the management of OA, “another point that I think is important and is a change from the previous guideline is the role of hyaluronic acid injections”, comments Kolasinski. The ACR considers adherence to the recommendations within this guideline to be voluntary, with the ultimate determination regarding their application to be made by the clinician in light of each patient's individual circumstances. In addition, limited and questionable health benefits from vitamin D supplementation have been suggested in other contexts 32, 33. Putting research into context. No effective disease‐modifying agents for OA have yet been identified though phase 2 and 3 trials are underway, and, for the time being, preventive strategies focus on weight management and injury prevention. A retrospective cohort study in 565 patients.. Nano wet milled celecoxib extended release microparticles for local management of chronic inflammation. The Voting Panel made strong recommendations for patients to participate in a regular, ongoing exercise program. Intraarticular glucocorticoid injections versus other injections are conditionally recommended for patients with knee, hip, and/or hand OA. MiR-146a-5p promotes IL-1β-induced chondrocyte apoptosis through the TRAF6-mediated NF-kB pathway. A multi-phase quality improvement project was conducted at the Dallas VAMC Rheumatology clinic to improve documentation of non … Implementing models of care for musculoskeletal conditions in health systems to support value-based care. Despite its popularity, only 1 published trial has addressed its potential role in OA. No recommendations were made for the other centrally acting agents due to lack of direct studies of relevance in OA. The ACR conditionally recommends against using chondroitin sulfate, glucosamine, or topical capsaicin for knee osteoarthritis. To develop an evidence‐based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Interventions with conditional recommendations in the 2012 guidelines that have now been upgraded to strong recommendations include: “Even though some of these are older interventions that have been around for a while,” the recommendations were strengthened in the latest update due to “a really comprehensive look at the literature,” comments Kolasinski. The quality and methods were compared with other guidelines and recommendations. Dr. Altman has received consulting fees, speaking fees, and/or honoraria from Flexion, GlaxoSmithKline, Novartis, Olatec, Pfizer, Sorrento Therapeutics, and Teva Pharmaceutical Industries (less than $10,000 each). Synergistic effects of hip/knee osteoarthritis and comorbidities on mobility and self-care limitations among older adults: Cross-sectional analysis of the Oxford pain, Activity and Lifestyle study. In addition, potential adverse effects, as well as drug interactions, may occur with use of colchicine. Use of the lowest possible doses for the shortest possible length of time is prudent, particularly since a recent systematic review and meta‐analysis suggests that less pain relief occurs during longer trials in the treatment of non‐cancer chronic pain 30. “We all wish that there were more options that were more effective for not only treating osteoarthritis, but preventing osteoarthritis or halting its progression, and we’re just not there yet.”. This study failed to show efficacy of a higher dose of fish oil over a lower dose. RFA = radiofrequency ablation; NSAIDs = nonsteroidal antiinflammatory drugs; IA = intraarticular. Although manual therapy can be of benefit for certain conditions, such as chronic low back pain, limited data in OA show little additional benefit over exercise alone for managing OA symptoms. The data that were deemed to have the lowest risk of bias fail to show any important benefits over placebo. . Studies using diathermy or ultrasound were more likely to be sham controlled than those using other heat delivery modalities. ACR 2020 Highlights: Dr. Anthony Fauci, Gout Guidelines, Osteoarthritis & Promoting Physical Activity. Supplementary Appendix 4 (http://onlin;elibr;ary.wiley.com/doi/10.1002/art.41142/;abstract) shows search terms used and databases reviewed, and Supplementary Appendix 5 (http://onlin;elibr;ary.wiley.com/doi/10.1002/art.41142/;abstract) highlights the study selection process. Learn about our remote access options, University of Pennsylvania School of Medicine, Philadelphia, Boston University School of Medicine, Boston, Massachusetts, University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, Arcadia University, Glenside, Pennsylvania, McMaster University, Hamilton, Ontario, Canada, Rush University Medical Center, Chicago, Illinois, University of North Carolina School of Medicine, Chapel Hill, South Holland Recreational Services, University of Chicago, and Ingalls Memorial Hospital, Thornton, Illinois, University of Michigan Medical Center, Ann Arbor, Tufts Medical Center, Boston, Massachusetts, University of Toronto, Toronto, Ontario, Canada, University of Arizona College of Medicine, Tucson, New York University Langone Medical Center, New York, New York, Ronald Reagan UCLA Medical Center, Los Angeles, California, Johns Hopkins University School of Medicine, Baltimore, Maryland, ECRI Institute, Plymouth Meeting, Pennsylvania, Cedars Sinai Medical Center, Los Angeles, California, American College of Rheumatology, Atlanta, Georgia. Although RCTs are considered the gold standard for evaluation, a number of limitations of RCTs proved particularly important in the formulation of the final recommendations: possible publication bias (favoring publication of positive results), inadequate blinding, and inadequate provision of active comparators and appropriate sham alternatives. Guidelines and recommendations developed and endorsed by the ACR are subject to periodic revision, as warranted by the evolution of medical knowledge, technology, and practice. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. In their last iteration, the ACR and OARSI guidelines began to propose clinical scenarios so as to move from evidence-based medicine to daily practice , . In favor of or against the use of Herbal Medications for treatment of knee osteoarthritis: life-long... 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