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Updated ACR Osteoarthritis Guideline Emphasizes Multimodal Approach and Self-Care

Home management in combination with medication and complementary therapies may better address patients’ daily function, joint pain, and related symptoms.

The American College of Rheumatology (ACR) and Arthritis Foundation have issued a joint updated guideline emphasizing the importance of provider-patient collaboration and multimodal, integrative approaches for the management of osteoarthritis (OA) and OA-related joint pain. The guideline, Management of Osteoarthritis of the Hand, Hip, and Knee, was released in early 2020 and also stresses the need for patients to take a more active role in managing their health.1

“The updates are significant because they call attention to the fact that OA is the most common form of arthritis, that OA is a significant cause of disability, and that there remains a broad research agenda to address in OA management,” said Sharon L. Kolasinski, MD, one of the guideline authors who serves as a professor of clinical medicine at theUniversity of Pennsylvania.

 

The ACR updates are significant because they call attention to the fact that osteoarthritis is the most common form of arthritis, that OA is a significant cause of disability, and that there remains a broad research agenda to address in OA management. (Image: iStock: Jan-Otto)

New Clinical Recommendations for Managing Osteoarthritis and Joint Pain

Dr. Kolasinski explained that the newest guideline addresses four key areas of change from an earlier version released in 2012, summarized below.

Take a Comprehensive Approach

Clinicians should take a comprehensive approach to the management of OA, choosing from a varied list of potential interventions. For instance, providers may take an educational, behavioral, psychosocial, mind-body, physical, and/or pharmacological approach. Decisions about which approach or approaches to use should be made based on each patient’s specific circumstances, including severity of the disease, the presence of other medical conditions, patient history of surgeries or injuries, and patient preference.

Dr. Kolasinki pointed out that it is important for clinicians to recognize that patients may experience a variety of additional symptoms as a result of the pain and functional limitations caused by OA. These may include mood disorders, altered sleep, chronic widespread pain, and impaired coping skills. 

“Measures aimed at improving mood, reducing stress, addressing insomnia, managing weight, and enhancing fitness may improve the patient’s overall well-being as well as their OA treatment success,” she advised.

 

Make Exercise & Weight Loss Part of the Care Plan

Exercise and weight loss remain central to the management of OA. “As in the 2012 guideline, we continue to strongly recommend the use of exercise to reduce pain and improve functioning for patients with osteoarthritis,” noted Dr. Kolasinki. “The variety of exercise options that are available and effective is broad, including aerobic activities (like walking and using a stationary bike), as well as strengthening, neuromuscular, and aquatic exercises.”

The guideline also maintains its  2012 recommendation regarding suggested weight loss in those patients with knee and hip OA who are overweight or obese.

 

Emphasize Self-Management & Complementary Therapies

The updated guideline includes additional interventions related to patient self-care. For example, recommendations for self-efficacy and self-management programs now suggest home practice of tai chi or yoga, cognitive behavioral therapy (CBT), and the use of OTC topical and oral NSAIDs.

"We included an expanded number of conditional recommendations in favor of the use of balance exercises, duloxetine, topical capsaicin for knee OA, yoga for knee OA, cognitive behavioral therapy, radiofrequency ablation therapy for the knee, and kinesiotaping for the first carpometacarpal joint and the knee,” added Dr. Kolasinki.

 

Focus Less on Meds

Finally, the updated guideline advises against the use of a number of pharmacologic interventions, including bisphosphonates, hydroxychloroquine, methotrexate, platelet-rich plasma injections, stem cell injections, tumor necrosis factor inhibitors, and interleukin 1 receptor antagonists to treat OA. The reason, noted Dr. Kolasinski said, is that a lack of consensus on their effectiveness remains.

 

Practical Takeaways

PPM spoke to Brett Smith, DO, a rheumatologist in Alcoa, Tennessee, about the impact of the updated guidelines on clinical practice. “The greatest takeaway from these guidelines, in my opinion, is the shift from ‘What can I do for my patient?’ to ‘What can my patient and I achieve together?’” he said.

He shared that the push for patient self-management and the focus on related OA symptoms, beyond joint pain, is also important. “Many times, patients believe they ‘just have arthritis’ and ‘there’s not much they can do,’ or they would like to know how to slow the process. This guideline gives us updated information on how to improve function, reduce pain, and incorporate other aspects of life such as mood, sleep, and stressors into the treatment plan,” Dr. Smith said.

“It is very difficult to obtain reasonable pain control if an individual has poor-quality sleep, circadian disruption, maladaptive stress coping skills, or ongoing moderate to severe depression,” he added. “That’s why, in addition to following the latest ACR guideline, the importance of incorporating our sleep medicine and mental health colleagues cannot be overstated.”

The update also reminds clinicians to set realistic expectations up front. This means talking about “pain reduction rather than elimination, working toward improved quality of life over complete restoration of function, and exploring the connection between mind and body with arthritis management,” said Dr. Smith.

With regard to pharmacological versus non-pharmacological based options, Dr. Smith shared that the medical community is “seeing increasing amounts of data and formal recommendations demonstrating the efficacy of non-pharmacologic management of OA, which I think should empower patients to work toward a better quality of life with physician guidance.”

 

Looking to Advances in Osteoarthritis Pain Care

While the ACR guideline provides important direction for clinicians, there are a number of research efforts under way exploring disease-modification approaches to OA management as well. “These are worth watching,” noted Dr. Smith.

For example, the anti–nerve growth factor (NGF) tanezumab, a humanized monoclonal immunoglobulin G2 antibody that blocks the pain response pathway by preventing NGF from binding to the receptors, is under final regulatory review. Slated to be available in late 2020 or 2021, this agent is thought to be a viable management strategy for individuals with moderate to severe osteoarthritis of the knee or hip. “While NGF does not provide any improvement in the amount of joint space narrowing, it does provide pain relief from a patient’s perspective,” Dr. Smith said.

Another promising approach is intra-articular injection of in vivo grade LNA-miR-181a-5p ASO, which in studies to date has reduced the amount of joint degradation in knee OA and reduced the amount of pro-inflammatory molecules in the joint. “This has not made it to human clinical trials yet, so we have no way to say that it is effective or safe, but it provides further insight into the disease and potential therapeutic targets,” shared Dr. Smith.

Overall, the updated ACR guideline in combination with promising new therapeutics may “help break cultural treatment habits that have low-quality evidence and could allow us to offer more effective therapies over time,” Dr. Smith said.

Last updated on: August 3, 2020
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