Guidelines Can Help Doctors Choose the Best OA Treatments
Consensus from American College of Rheumatology stresses exercise and weight loss, but are doctors following the guidelines?
Whether osteoarthritis (OA) affects your knees, your hips or your hands, guidelines and recommendations published by groups including the American College of Rheumatology (ACR) can help your doctor determine the best course of treatment based on the most current treatment research in the field. However, a study published in Arthritis Care & Research in 2011 revealed that many doctors don’t follow these guidelines when prescribing treatment and thus may rely too heavily and too quickly on medications and surgery when research shows more conservative measures such as exercise and weight loss should be recommended first.
In developing guidelines for the treatment of hip and knee OA, the ACR assembled a panel of experts – including academic and practicing rheumatologists, primary care physicians, physiatrists, geriatricians, orthopaedic surgeons, and occupational and physical therapists – who evaluated more than 50 drug and non-drug treatments used in the U.S. and Canada to manage OA, assessing their effectiveness as well as the quality of evidence supporting them.
Based on their findings, the ACR issued a range of drug and non-drug recommendations. Two of the strongest are for land-based exercise and for weight loss when needed. “People with OA exercise less than the general population, yet exercise is critical for strength, flexibility and balance. There is good data showing that pain is reduced, functioning increased and surgery delayed with an exercise program,” says Sharon Kolasinski, MD, professor of medicine at Cooper Medical School in Camden, N.J., who was not involved in drafting the recommendations. “No intervention can halt the progression of OA, but exercise and weight loss are particularly important [for quality of life].”
Similarly, OA treatment guidelines by the European League Against Rheumatism (EULAR) and the American Academy of Orthopaedic Surgeons stress the importance of exercise and weight loss as a first line of OA treatment.
After exercise and weight loss, the ACR also recommended
acetaminophen, oral nonsteroidal anti-inflammatory drugs (NSAIDs), the synthetic opioid tramadol and corticosteroid joint injections;
topical rather than oral NSAIDs for people over 75, who are at higher risk from developing complications from oral NSAIDs; the COX-2 inhibitor celecoxib (Celebrex) or a traditional NSAID along with a stomach-protective drug, such as esomeprazole (Nexium) or omeprazole (Prilosec) for younger people at high risk of gastrointestinal side effects;
opioids such as hydrocodone for people who don’t respond to other treatments and aren’t candidates for joint replacement; (The panel cautioned that doctors who prescribe them should follow guidelines established by the American Pain Society and the American Academy of Pain Medicine.)
tai chi, acupuncture, TENS (transcutaneous electrical nerve stimulation) or intra-articular hyaluronate injections for knee OA, but not hip OA.
The ACR has not established guidelines for treatment of OA of the hand; however, it has published conditional recommendations for initial non-drug treatment. These recommendations include a physician assessment of the patient’s ability to perform daily tasks, as well as use of assistive devices as needed and splints for thumb OA.
Drug recommendations for OA of the hand also include oral or topical NSAIDs – topical rather than oral for patients older than 75 – as well as tramadol and capsaicin, a topical pain reliever derived from chili peppers. The panel made no strong recommendations because supporting evidence for various interventions was weak or insufficient.
Doctors Not Following Guidelines
Despite the availability of treatment guidelines and recommendations, only 5 to 10 percent of clinicians manage patients in a way that is consistent with them, says David Hunter, MD, PhD, a professor of medicine at University of Sydney in Australia and author of the 2011 study in Arthritis Care & Research which reviewed medical and scientific literature to determine the treatments clinicians were prescribing for their patients with OA.
“Typically what happens in clinical practice is pharmacologic intervention and then, when this is insufficient for pain relief, surgical referral with almost complete neglect of important non-pharmacologic treatments,” Dr. Hunter says.
Dr. Hunter doesn’t know why that is but doesn’t think it’s a lack of education on the part of the clinicians. “They know what needs to be done, but the processes to make this happen are more complex than writing a prescription for a pain medication,” Dr. Hunter says. “Taking a pill is definitely easier than losing weight through diet and exercise. But the long-term management of this disease is not enhanced by the short-term outlook.”
David Pisetsky, MD, a professor of medicine at Duke University in Durham, N.C., and a practicing rheumatologist, points out that while guidelines are based on the population as a whole, doctors treat individuals. “Guidelines are guidance. They aren’t an absolute way. I think you have to leave it up to the clinician and patient to come up with what’s best for them,” Dr. Pisetsky says. “You have to respond to the patient’s needs. And sometimes it means immediately starting pain therapy and doing other things early. I think it’s very hard.”
Dr. Hunter agrees the issue is complex and says, going forward the medical community needs to set up electronic processes to remind doctors what they should do. He says patient awareness programs are key, too – so individuals are educated about options and can make informed decisions.
“Empowering and educating patients can go a long way to moving toward appropriate management,” Dr. Hunter says.