The American College of Rheumatology (ACR) has released updated recommendations for the treatment of osteoarthritis of the hip and knee, and has developed new recommendations for the treatment of osteoarthritis of the hand. These recommendations are categorized as strong or conditional. A strong recommendation indicates that most patients, when informed of the quality of the evidence supporting the use of a therapy and the degree to which its benefits outweigh its harms, would choose the recommended therapy, and that physicians may structure their interactions with patients accordingly. A conditional recommendation indicates that although most informed patients would choose the recommended therapy, many would not; therefore, physicians should ensure that the care they recommend is in keeping with their patients' values and preferences.

Recommendations for Osteoarthritis of the Hand

NONPHARMACOLOGIC

The ACR conditionally recommends that physicians evaluate a patient's ability to perform activities of daily living and provide assistive devices to help patients perform these activities, if needed. In addition, patients should be instructed in the use of thermal modalities and other techniques that help protect their joints, including splints for patients who have osteoarthritis of the trapeziometacarpal joint.

PHARMACOLOGIC

Conditional recommendations for the initial pharmacologic management of hand osteoarthritis include oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as cyclo-oxygenase-2 selective inhibitors, and topical NSAIDs (e.g., trolamine salicylate). Topical capsaicin (Zostrix) and tramadol (Ultram) are also conditionally recommended.

In patients 75 years and older, the ACR conditionally recommends that physicians prescribe topical rather than oral NSAIDs. In patients younger than 75 years, there is no preference between topical and oral NSAIDs.

Intraarticular therapies and opioid analgesics are conditionally not recommended for initial therapy.

Recommendations for Osteoarthritis of the Knee

NONPHARMACOLOGIC

The ACR strongly recommends that patients with knee osteoarthritis participate in an aquatic exercise program, and in aerobic or resistance land-based exercise programs. Patients who are overweight should be advised about losing weight.

Self-management programs, manual therapy in combination with a supervised exercise program, psychosocial interventions, and use of medially directed patellar taping are conditionally recommended. Patients should also be instructed in the use of thermal agents, and receive walking aids if needed.

Other conditional recommendations include encouraging patients to participate in tai chi programs, to receive instruction in the use of transcutaneous electrical stimulation, and to be treated with traditional Chinese acupuncture. Of note, traditional Chinese acupuncture and transcutaneous electrical stimulation are recommended only when a patient with knee osteoarthritis has chronic, moderate to severe pain and is a candidate for total knee arthroplasty, but is unwilling to undergo arthroplasty, has comorbid medical conditions, or is taking medications that would contraindicate surgery or that would lead a surgeon to not recommend the procedure.

If patients have lateral compartment osteoarthritis, they should wear medially wedged insoles. For medial compartment osteoarthritis, patients should wear laterally wedged subtalar strapped insoles.

The ACR has no specific recommendations with regard to patients participating in balance exercises (alone or in combination with strengthening exercises), receiving manual therapy alone, using laterally directed patellar taping, or wearing knee braces or laterally wedged insoles.

PHARMACOLOGIC

Conditional recommendations for initial management of knee osteoarthritis include acetaminophen, intraarticular corticosteroid injections, oral or topical NSAIDs, and tramadol. The ACR also conditionally recommends that patients with knee osteoarthritis avoid chondroitin, glucosamine, or topical capsaicin preparations. The ACR has no recommendations concerning the use of duloxetine (Cymbalta), intraarticular hyaluronate injections, or opioid analgesics.

Recommendation for Osteoarthritis of the Hip

NONPHARMACOLOGIC

The ACR strongly recommends that patients with hip osteoarthritis participate in aquatic exercise programs and in aerobic or resistance land-based exercise programs. If a patient is overweight, he or she should be advised to lose weight.

The ACR conditionally recommends that patients with hip osteoarthritis be instructed in the use of thermal agents, participate in self-management programs, receive walking aids (if needed) and manual therapy (in combination with supervised exercise), and receive psychosocial interventions.

The ACR has no specific recommendations regarding participation in balance exercises (alone or in combination with strengthening exercises) or tai chi programs, or receiving manual therapy alone.

PHARMACOLOGIC

Conditional recommendations for the initial management of hip osteoarthritis include acetaminophen, intraarticular corticosteroid injections, oral NSAIDs, and tramadol. The ACR also conditionally recommends that patients avoid chondroitin and glucosamine. The ACR has no specific recommendations about using duloxetine, intraarticular hyaluronate injections, opioid analgesics, or topical NSAIDs.