The 2012 ACR guidelines for osteoarthritis: Not a cookbook

Some drugs for hand osteoarthritis got conditional recommendations in favor

The expert panel gave conditional recommendations in favor of:

• Topical capsaicin
• Topical NSAIDs
• Oral NSAIDs (including both nonselective and selective agents)
• Tramadol (Ultram)
• Topical rather than oral NSAIDs for patients age 75 and older.

Other drug treatments got conditional recommendations against their use

The expert panel gave conditional recommendations against using:

• Intra-articular injections, and in particular, corticosteroid injections in the trapeziometacarpal (first carpometacarpal) joint
• Opioid analgesics
• Oral methotrexate or sulfasalazine in patients with erosive inflammatory interphalangeal osteoarthritis.

No recommendation for or against

• Hydroxychloroquine.

Comments—Intra-articular injections, opioids, and oral NSAIDs

I differ with these recommendations on several points.

Although the guidelines committee conditionally recommended against using intra-articular therapies for hand osteoarthritis, I find that intra-articular corticosteroid injections are often effective, particularly in patients who have inflammatory forms of the disease, ie, “erosive inflammatory osteoarthritis.” Most nonspecialist physicians probably have limited experience in giving injections into small joints, and referral to a rheumatologist or orthopedist would be appropriate.

I disagree as well with the conditional recommendation that intra-articular corticosteroid injections not be used for involvement of the trapeziometacarpal (first carpometacarpal) joint. I find that many patients with osteoarthritis of this joint experience improvement with intra-articular corticosteroid injections.

I agree that there are limited data on the use of intra-articular hyaluronan injections in this situation and do not routinely use them in this joint.

Opioid analgesics also received a conditional recommendation against their use. The same caveats apply here as for these drugs elsewhere.⁵ If used, opioids should be used at the lowest dose possible and for as short a time as possible. If the physician is uncomfortable prescribing opioids for patients with osteoarthritis, referral to a pain specialist is recommended.

I disagree to some extent with the conditional recommendation that people age 75 and older should use topical rather than oral NSAIDs. I understand the recommendation, given that older people have a higher frequency of gastrointestinal, renal, and cardiac disease and are best served by avoiding NSAIDs. However, we all see patients over age 75 who are physiologically younger than their numerical age. Accordingly, I feel that the judgment of the physician plays a role in whether NSAIDs are reasonable for some older patients.

The committee recommended not using oral methotrexate or sulfasalazine in patients with erosive inflammatory interphalangeal osteoarthritis. I have used oral hydroxychloroquine off-label in such patients and find that they respond in a very rewarding fashion.

Given that this is an off-label use of hydroxychloroquine, the drug should be used only with appropriate consideration and after discussion with the patient about toxicity, especially about the risk of ocular manifestations.

OSTEOARTHRITIS OF THE KNEE

Some nondrug therapies got strong recommendations

The expert panel strongly recommended:

• Exercise (aerobic, resistance, land-based, and aquatic)
• Weight loss (for patients who are overweight).

Other nondrug therapies got conditional recommendations

The panel conditionally recommended:

• Self-management programs
• Manual therapy in combination with supervised exercise
• Psychosocial interventions
• Medially directed patellar taping
• Medially wedged insoles (if the patient has lateral compartment osteoarthritis)
• Laterally wedged subtalar strapped insoles (if the patient has medial compartment osteoarthritis)
• Heat therapy
• Walking aids, as needed
• Tai chi
• Chinese acupuncture
• Transcutaneous electrical nerve stimulation.

Comments. The ACR panel appropriately noted that Chinese acupuncture or transcutaneous electrical stimulation should be recommended only if the patient has chronic moderate to severe pain and is a candidate for total knee arthroplasty but is unwilling to undergo the procedure or has comorbid medical conditions that rule out surgery.

Nondrug therapies for knee osteoarthritis that got no recommendation for or against

• Balance exercise
• Laterally wedged insoles
• Manual therapy alone
• Knee braces
• Laterally directed patellar taping.

Comments. It was somewhat surprising that there were no recommendations about laterally wedged insoles or knee braces. Laterally wedged insoles have been recommended for patients who have medial compartment knee osteoarthritis⁶; being thinner at the instep and thicker at the outer edge of the foot, they reduce load on the medial aspect of the knee. One has to be cautious in using knee wedging in patients who have concomitant ankle or hip angle deformities, lest these joints be compromised.

Some of these treatments would be out of the realm of the nonspecialist physician.

Conditional recommendations for initial drug therapy for knee osteoarthritis

The panel conditionally recommended that patients who have osteoarthritis of the knee use one of the following:

• Acetaminophen (contained in Tylenol and a host of other products)
• Oral NSAIDs
• Topical NSAIDs (with a strong recommendation for topical NSAIDs rather than oral NSAIDs in patients age 75 and older)
• Tramadol
• Intra-articular corticosteroid injections.

Comments. In the past, it was recommended that acetaminophen in full doses of up to 4,000 mg per day be considered.⁷ Current dogma, however, is that doses of acetaminophen should not exceed 3,000 mg per day to avoid damaging the liver. This concern led the US Food and Drug Administration (FDA) in 2011 to advise that the maximum daily dose be limited.⁸ The ACR panel recommended that patients be counseled to avoid all other products that contain acetaminophen, which is especially cogent, given the presence of this agent in many over-the-counter medications.⁹

The panel conditionally recommended that people age 75 and older use topical rather than oral NSAIDs. As mentioned earlier, a specific age limit does not take into account that many people age 75 and older may actually be physiologically younger than some in their 50s or 60s. Accordingly, it is recommended that the physician use judgment in this regard so that NSAIDs will not be denied to patients for whom they might be of significant value.