ACR, Arthritis Foundation guidelines favor nondrug therapy over TENS, stem cells for OA
ATLANTA — Health care providers should avoid prescribing transcutaneous electric nerve stimulation or stem cell injections in favor of more comprehensive management — including nonpharmacological interventions such as tai chi — for hip, knee and hand osteoarthritis, according to draft guidelines presented at ACR/ARP 2019.
“The new guideline emphasizes a comprehensive approach to the management of osteoarthritis rather than stepwise linear management,” Sharon L. Kolasinski, MD, of the division of rheumatology at the University of Pennsylvania, said in a press conference.
“Education, mind-body approaches, psychosocial interventions, pharmacological approaches, any given choice can be made any time point, and may be used again in the future. One option might be useful for a while but then others will take its place upon comprehensive evaluation of the patient.”
The ACR has partnered with the Arthritis Foundation to create the guidelines, which were authored by a core team that identified 44 potential interventions for patients with osteoarthritis. The development team included five groups, one of which was a patient panel.
After formulating the Population/Intervention/Comparison/Outcome (PICO) questions, the document was posted on the web for public comment. Then came the literature review, which began with more than 8,000 articles and ultimately included 536 papers.
The forthcoming document offers some marked differences from the last iteration of the recommendations, which were published in 2012.
For example, in contrast with 2012, self-efficacy and self-management are strongly, not conditionally, recommended for knee and hip OA. Other recommendations that jumped from conditional to strong include the use of tai chi for knee and hip OA, topical NSAIDs for knee and hand OA, and oral NSAIDs and intra-articular steroids for knee and hip OA.
“There is an expanded number of strong recommendations this time,” Kolasinski said. “They cover everything from mind-body to pharmacotherapeutic approaches.”
Other departures from the 2012 document include a new conditional recommendation for balance exercises in patients with knee and hip OA, and duloxetine for knee OA.
In 2012, topical capsaicin was conditionally contraindicated for knee OA, but it is now conditionally recommended.
Yoga, cognitive behavioral therapy, radiofrequency ablation and kinesiotaping for first carpometacarpal and knee OA are now conditionally recommended.
Tuhina Neogi, MD, PhD, professor of epidemiology at the Boston University School of Public Health and chief of rheumatology at the Boston Medical Center, addressed some of these so-called nonpharmacological interventions. “These physical modalities are really underutilized despite the fact that we have a lot of evidence supporting their use,” she said. “But more importantly, we need to change the language and change the way we approach these interventions with our patients.”
Neogi suggested that when patients hear the “non” in “nonpharmacological,” they feel as though they are not being treated. “We need to let them know that even though it does not involve medications, this is medicine,” she said.
As for other contraindications, the authors strongly recommend against transcutaneous electric nerve stimulation (TENS), chondroitin, platelet-rich plasma injections and stem cell injections for knee and hip OA.
There are also conditional recommendations against manual therapy for knee and hip OA, and against intra-articular hyaluronic acid injections in first carpometacarpal and knee OA. “The voting panel actually spent quite some time reviewing the literature for hyaluronic acid,” Neogi said. “Some of the studies looking at this intervention were problematic with risk of bias, blinding, and trial size.”
Other considerations that gave the guideline development team pause were those associated with acetaminophen and opioids, according to Neogi. “There was a strong discussion of whether acetaminophen should even appear in the guidelines anymore because it has minimal, if any, efficacy,” she said. “But we wanted to make sure we heard the patient voice, so acetaminophen may be used as an option for patients with contraindications.”
As for opioids, both patients and the experts on the guideline development team understand the risks. “Patients do not generally want opioids, but they wanted to have them as an option anyway if nothing else is working for them,” Neogi said.
The recommendations are still under review, with publication expected in the spring of 2020. – by Rob Volansky
Kolasinski S. 2019 ACR/AF guideline for the management of OA of the hand, knee and hip. Presented at: American College of Rheumatology/Association of Rheumatology Professionals Annual Meeting; Nov. 9-13, 2019; Atlanta.
Disclosure: Kolasinski and Neogi report no relevant financial disclosures.