Commentary

The 2012 ACR guidelines for osteoarthritis: Not a cookbook

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“When I see a patient with arthritis coming in the front door, I leave by the back door.”
—Sir William Ostler

Fortunately for today’s physicians treating patients with osteoarthritis, we need not be as pessimistic as Osler was more than a century ago when he uttered his now-famous words. Still, there is no magic bullet for the contemporary clinician treating an elderly patient with osteoarthritis. Instead, there are many imperfect bullets, and choosing between them is always a balancing act between benefit and risk from various agents: nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics such as acetaminophen and tramadol, opioids, and supplements such as glucosamine and chondroitin sulfate.

So there was great interest when, in 2012,1 the American College of Rheumatology (ACR) updated its previous guidelines (from 2000) on drug and nondrug therapies for osteoarthritis of the hip and the knee2 and added new recommendations on osteoarthritis of the hand.

Revising the guidelines was appropriate, since new therapies have become available. But, as the guideline authors state, with osteoarthritis, as with other diseases, guidelines cannot be a “cookbook.”

The treatment approach differs depending on the patient’s clinical presentation and on the preferences of the patient and the physician. Often, more than one approach is possible, and more than one approach may be appropriate in a given patient at a given time. The guideline authors also point out that some physicians may disagree with some of the recommendations.

I wish to review here several of the key recommendations. But I also provide some of my personal perspective and experience after 4 decades of treating patients with osteoarthritis.

HOW THE GUIDELINES WERE MADE

The new ACR guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, a formal process to develop recommendations that are as evidence-based as possible.3

The authors are outstanding experts in the field of osteoarthritis from throughout the United States and Canada. Further, the recommendations were voted on by a “technical expert panel” representing the fields of rheumatology, orthopedics, physical medicine, and rehabilitation, from both academic medicine and private practice. This representation provides a balance of input from the types of clinicians frequently involved in managing osteoarthritis.

The initial literature searches for drug therapies were conducted during late 2008, and those for nonpharmacologic treatments were conducted during the second and third quarters of 2009. The goal of the literature searches was to identify the most current systematic reviews and meta-analyses that would provide reliable estimates of benefits of intervention for the prespecified clinically relevant outcomes of pain and function, as well as data on safety.

Recommendations: For or against, strong or weak—and the informed patient’s perspective

Therapies received the following possible recommendations:

  • Strong recommendation to use
  • Weak (or conditional) recommendation to use
  • No recommendation
  • Weak (or conditional) recommendation not to use
  • Strong recommendation not to use.

A strong recommendation required high-quality evidence and evidence of a large difference between desirable and undesirable effects of the treatment. A conditional recommendation was based on the absence of high-quality evidence, evidence of only a small difference between desirable and undesirable effects of the treatment, or both.

One interesting feature of these recommendations is that they took into account how informed patients might themselves evaluate the data with their medical condition.

For instance, if a therapy received a strong favorable recommendation, we can assume that most informed patients would choose to receive it, and we can shape our interaction with the patient accordingly. A conditional recommendation means that most informed patients would choose the treatment—but many would not, and physicians should keep the patient’s values and preferences in mind.

I admit I had a problem with the meaning of the word “conditional” in the context of these guidelines. When evaluating a treatment, the term “weak” is readily understood and clearer. By using the word “weak,” one is making a positive statement in support of use but letting you know that the data and recommendation are weak. The word “conditional” is less readily defined and does not necessarily imply support for use.

Recommendations were drafted after discussion of the evidence at each meeting of the technical expert panel. Consensus was defined as 75% or more of the members of the panel voting to either strongly or conditionally recommend using a therapy, to either strongly or conditionally recommend not using it, or to choose not to make a recommendation on its use.

OSTEOARTHRITIS OF THE HAND: NO STRONG RECOMMENDATIONS

The technical expert panel gave no strong recommendations for any nondrug or drug treatment for osteoarthritis of the hand.

Conditional recommendations for nondrug treatments

The panel conditionally recommended the following:

  • All patients with osteoarthritis of the hand should be evaluated either by their primary physician or by an occupational or physical therapist, particularly with respect to ability to perform activities of daily living.
  • Assistive devices such as jar openers, key turners, and pull tabs for zippers should be recommended, as needed.
  • Patients should be instructed in joint protection and in the use of thermal treatments (eg, heating pads, ultrasound devices, hot packs, and ice packs).

Comments. Appliances are often beneficial in patients who have involvement of the first carpometacarpal (trapeziometacarpal) joint. Although over-the-counter thumb splints are an option, referral to an occupational therapist for splint prescription is advantageous to achieve a comfortable fit and, importantly, for instructions to the patient on how to avoid joint trauma.

It would be unrealistic to expect primary care physicians and internists to have the expertise to make detailed recommendations about orthopedic appliances. Accordingly, referral to an occupational therapist or an orthopedist is advisable for these situations. It is important, however, that the physician be aware of what treatments are available and most effective, and of the indications for referral.

As for heat treatment, elastic stretch gloves may relieve symptoms through their warming and massaging effects.4

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