The 2012 ACR guidelines for osteoarthritis: Not a cookbook

Conditional recommendation against glucosamine, chondroitin, capsaicin

The ACR panel conditionally recommended that patients with knee osteoarthritis not use:

• Chondroitin sulfate
• Glucosamine
• Topical capsaicin.

Comment. Evidence is mixed about the efficacy of glucosamine and chondroitin sulfate, which are so-called nutraceuticals. Some studies found them useful^23–25 but some did not,²⁶ and a meta-analysis concluded that they do not help.²⁷ The OARSI guidelines published in 2008 stated that these agents may relieve symptoms of osteoarthritis of the knee.⁷ The OARSI update published in 2010 found that glucosamine was effective, but less so than in previous studies.²² If glucosamine is effective, some studies suggest that glucosamine sulfate is more effective than glucosamine hydrochloride.²²

The same OARSI review revealed that chondroitin sulfate relieved pain but with heterogeneous, dissimilar effect sizes. Of interest was the finding that the 5-year incidence of total knee replacement was lower in patients treated with glucosamine sulfate 1,500 mg/day than with placebo. Also, the rate of decline of joint space narrowing was reported to be reduced in chondroitin sulfate-treated patients.²²

In practice, a conditional recommendation against a treatment means that most informed patients would not want the treatment, but some would. Accordingly, if patients still want to take chondroitin or glucosamine after being informed of the limited evidence of benefit, I feel a trial of their use is reasonable.

OSTEOARTHRITIS OF THE HIP

Indications for therapy of osteoarthritis of the hip are similar to those for osteoarthritis of the knee.

As in the knee, nonpharmacologic therapies are important. Loss of weight for overweight patients is extremely important; supervised exercise is especially valuable. Use of canes or crutches as needed is conditionally recommended.

Pharmacologic management is similar to that of osteoarthritis of the knee, with particular use of acetaminophen, NSAIDs, tramadol, and intra-articular corticosteroid injections.

Comment. Intra-articular injection of corticosteroids into the hip would be out of the realm of most nonspecialist practices. Although some rheumatologists are expert in such injections, this treatment is generally best left to an orthopedist or invasive radiologist. The use of ultrasonographic guidance is becoming more frequent, with many rheumatologists having developed expertise in this approach to the knee and the hip. Since most studies were in patients with osteoarthritis of the knee, fewer data are available as to the efficacy of these agents in patients with hip osteoarthritis.

Fewer data are available also with respect to the benefit of chondroitin sulfate and glucosamine in patients with osteoarthritis of the hip. Total joint replacement is extremely effective if conservative therapy does not help.

FIRST, DO NO HARM

Guidelines from the ACR,^1,2 the European League Against Rheumatism (EULAR),^28,29 the American Academy of Orthopedic Surgeons (AAOS),³⁰ and the OARSI^7,22 all differ somewhat, owing to the different evidence available at the time each guideline was developed and to different geographic and cultural backgrounds.

The compositions of these various panels also differ sufficiently to affect their overall recommendations. For example, the EULAR panel consisted of only rheumatologists and an orthopedic surgeon; for the hand osteoarthritis recommendations they added a physiatrist and two allied health professionals.^28,29 The OARSI panel included two primary care physicians in addition to rheumatologists and an orthopedic surgeon.⁷ The ACR was the only professional society to include primary care physicians, physiatrists, and geriatricians along with rheumatologists, an orthopedic surgeon, and physical and occupational therapists.

Although it is to be expected that there will not be universal agreement on all points of management of osteoarthritis by diverse groups, it is essential that input from all these experts representing various subspecialties be recognized. Therapeutic approaches will vary depending on patient characteristics and the experience of the treating physician. As long as therapy is based on reasonable supportive data, beneficial effects can be anticipated. Therapies that received conditional recommendations are not to be discounted if a reasonable percent of patients respond in positive fashion. Obviously, strong recommendations are more likely to be universally accepted since the likelihood that they will be beneficial is stronger.

In any approach to therapy, the caveat primum non nocere—first, do no harm—must always be kept in mind.