The 2012 ACR guidelines for osteoarthritis: Not a cookbook
Strong recommendation for gastric protection in patients at risk on NSAIDs
If a patient with knee osteoarthritis has a history of a symptomatic or complicated upper gastrointestinal ulcer but has not had an upper gastrointestinal bleed in the past year and the physician chooses to prescribe an oral NSAID, the expert panel strongly recommended using either a cyclooxygenase (COX)-2-selective inhibitor or a nonselective NSAID in combination with a proton pump inhibitor.
Comment. The suggestion that patients who have had a complicated upper gastrointestinal ulcer in the past year could be considered for treatment with a COX-2-selective inhibitor or nonselective NSAID in combination with a proton pump inhibitor seemed a bit aggressive. My own inclination would be to avoid both nonselective and selective inhibitors in this situation. Alternative agents such as acetaminophen in full doses, tramadol, intra-articular hyaluronan injections, and intra-articular corticosteroid injections seem preferable with respect to safety in such patients.
The suggestion that a proton pump inhibitor be used whenever an NSAID is given for chronic management of knee or hip osteoarthritis is reasonable.10,11 Although some studies have suggested that chronic use of proton pump inhibitors may predispose to osteopenia or osteoporosis, others have not, and gastric protection should be considered in patients at gastrointestinal risk.
Strong recommendation against ibuprofen in patients taking aspirin
The ACR panel strongly recommended that ibuprofen (Advil) not be prescribed to patients with knee osteoarthritis who are using aspirin in low doses for cardioprotection, and strongly recommended using another nonselective NSAID plus a proton pump inhibitor instead. The panel also strongly recommended against using a COX-2-selective inhibitor in this situation.12,13
Comment. The rationale for these recommendations is that ibuprofen may render aspirin ineffective as a cardioprotective agent. Ibuprofen interferes with the aspirin-binding site on platelets, so that the protective effect of aspirin is lost.14,15 Celecoxib (Celebrex)16 and diclofenac (Voltaren) have binding sites different from that of aspirin, although the ACR recommends against using COX-2-selective inhibitors such as celecoxib in the situation and gives no recommendation about other NSAIDs.
No recommendations for or against
The panel issued no recommendations for or against the following treatments for patients with knee osteoarthritis:
- Intra-articular hyaluronan injections
- Duloxetine (Cymbalta)
- Opioid analgesics.
Comments on knee injections
Intra-articular injections of corticosteroids or hyaluronan are commonly used for knee osteoarthritis. As noted, corticosteroid injections received a conditional recommendation, while hyaluronan injections received no recommendation for or against.
How often to inject corticosteroids? In general, too-frequent injection of corticosteroids is to be avoided, in view of the risk of promoting joint breakdown. There is no “magic” number of injections that is safe, although more than 4 per year in the same joint should generally be avoided. In some situations, however, repeat injections may be reasonable if alternative therapies are associated with higher risk.
Raynauld et al,17 in a randomized, double-blind, placebo-controlled trial, demonstrated that intra-articular corticosteroid injections at 3-month intervals for 2 years were not deleterious to knees.
My philosophy is generally not to inject on a regular basis, but to be selective and be guided by the patient’s clinical condition and response to prior injections.
Are hyaluronan injections effective? Although experts differ in their enthusiasm for intra-articular hyaluronan injections in the knee, I have found that many patients benefit from this treatment. Multiple studies have found it efficacious and safe overall.18–21 However, some systematic reviews have called its efficacy into question.7
Although differences in efficacy have been noted, this therapy was approved as being useful in patients with knee osteoarthritis in the Osteoarthritis Research Society International (OARSI) recommendations.7 The effect sizes were smaller in later assessments.22
Hyaluronan injections do not pose the risk of joint breakdown that corticosteroid injections do, but their clinical efficacy is not as dramatic. Adverse reactions to most intraarticular hyaluronans are limited, with slight increases in pain and stiffness after injection. Significant inflammatory reactions characterized as “postinjection flares” are more commonly seen with high-molecular-weight crosslinked preparations. These reactions can be severe and can mimic joint infection clinically. Joint aspiration with synovial fluid analysis and culture may be necessary to exclude infection. Response to aspiration and nonsteroidal inflammatory agents or intra-articular corticosteroids is usually excellent.
Ultrasonographic guidance. As with intraarticular injections in other areas, ultrasonographic guidance is becoming more common, as it allows for more accurate drug administration.
Pes anserine bursitis must be ruled out as a cause of the patient’s knee symptoms—misdiagnosis is not uncommon. The bursa is located on the medial aspect of the tibia, and inflammation of the bursa is a common cause of pain in this area. Local steroid injection is extremely effective in symptomatic therapy. Physical therapy and NSAIDs may be adequate to treat milder cases.
