Fuente: http://www.arthritistoday.org/news/osteoarthritis-treatment-guidelines190.php
New Recommendations for Hand, Knee and Hip Osteoarthritis
Consensus from American College of Rheumatology stresses exercise, weight loss.
By Linda Rath
4/10/12 For the first time in more than a decade, the American College of Rheumatology, or ACR, has updated its recommendations for thetreatment of osteoarthritis, or OA, of the knee and hip, and issued its first-ever recommendations for hand OA.
The authors of the recommendations (which are less formal than guidelines) write that they are “not intended to be used in a ‘cookbook’ fashion, but rather to provide guidance based on clinical evidence and expert panel input.”
The aim is to provide rheumatologists, general practitioners and patients a guide to proven, effective treatments based on the best available evidence, says Marc C. Hochberg, MD, professor of medicine at the University of Maryland School of Medicine in Baltimore and chair of the ACR’s OA guideline committee.
The recommendations, which were published in the April issue of Arthritis Care & Research, were updated to take into account the latest studies and better ways to weigh medical evidence developed since the last recommendations were issued in 2000. Important new additions (aside from the hand OA recommendations) include recommendations on the use of glucosamine, chondroitin sulfate, opioids and topical nonsteroidal anti-inflammatory drugs, or NSAIDs.
To formulate the ACR recommendations, a panel of experts – including academic and practicing rheumatologists, primary care physicians, physiatrists, geriatricians, orthopaedic surgeons, and occupational and physical therapists – 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.
In cases where the panel determined evidence was high-quality – for example, because it was based on several randomized, controlled trials – the recommendation (either for or against) was rated “strong.” Weaker evidence – for example, because the benefits of a treatment did not clearly outweigh the potential risks, or because the quality of the studies was inferior – led to a “conditional” rating. And in cases where evidence was insufficient, the panel chose not to issue a recommendation.
Approval of the recommendations was consensus-based, requiring agreement among at least 75 percent of panel members.
Treatments for Hip and Knee OA
The panel issued a range of drug and non-drug recommendations for treating knee and hip OA. Two of the strongest are for land-based exercise or aquatic exercise and for weight loss when needed.
Sharon Kolasinski, MD, professor of medicine at Cooper Medical School in Camden, N.J., who was not involved in drafting the recommendations, says the emphasis on exercise is important.
“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,” she says. “No intervention can halt the progression of OA, but exercise and weight loss are particularly important [for quality of life].”.
A separate study published in the January 2011 issue of Arthritis Care & Research found that many doctors were not following standard-care guidelines when treating patients – for example moving straight to prescription medication and surgery instead of first recommending exercise and weight loss.
In terms of medications, no drug therapies receive strong support, but the panel conditionally recommends acetaminophen, oral NSAIDs, the synthetic opioid tramadol and corticosteroid joint injections.
For knee OA in patients older than 75 years old, the panel strongly recommends the use of topical rather than oral NSAIDs – a new addition to the recommendations. (Topical NSAIDs were first approved by the U.S. Food and Drug Administration in 2007.) Because they are applied to the skin, topicals are thought to cause less stomach bleeding and fewer other side effects than oral NSAIDs; people older than 75 are at higher risk for developing these complications.
For younger people at high risk of gastrointestinal side effects, the panel recommends the COX-2 inhibitor celecoxib, or Celebrex, which was designed to protect the stomach, or a traditional NSAID along with a stomach-protective drug, such as a proton-pump inhibitor, a class of drug that includes esomeprazole, or Nexium, or omeprazole, or Prilosec.
And for people who don’t respond to other treatments and aren’t candidates for joint replacement, the panel strongly endorses opioids such as hydrocodone, but cautions that doctors who prescribe them should follow guidelines established by the American Pain Society and the American Academy of Pain Medicine.
In one of its admittedly more controversial moves, the panel conditionally recommends against using chondroitin sulfate and glucosamine for knee and hip OA. The ACR withheld judgment on the supplements in 2000.
“The body of evidence from recent North American studies … failed to demonstrate efficacy for [these supplements] greater than placebo, so the panel felt the evidence did not support their use,” explains Dr. Hochberg, adding that forms of the supplements tested in the U.S. are different from those in Europe found to be safe and effective.
Although the recommendations for hip and knee OA were similar overall, they did diverge. For hip OA, there was insufficient evidence to recommend tai chi, acupuncture, TENS (transcutaneous electrical nerve stimulation) or intra-articular hyaluronate injections. However, for knee OA, all of these treatments were conditionally recommended.
A New Focus on Hand OA
In addressing hand OA for the first time, the panel made no strong recommendations because supporting evidence for various interventions was weak or insufficient.
Conditional recommendations for initial non-drug treatment 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.
Conditional drug recommendations 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, which is no longer recommended for knee and hip pain.
The authors of the recommendations write, “As new evidence continues to be developed, it is likely that these recommendations will need to be updated and/or revised.”
Dr. Kolasinski says she is encouraged that the updated ACR recommendations address long-neglected hand OA, which is debilitating for many people, and that there is an emphasis on exercise for knee and hip OA. Although, she says, “Over the last decade we haven’t made as much progress as we would like in pharmacological interventions in OA.”
Dr. Hochberg sees things differently. “It’s important for people to recognize that there are a lot of interventions available to them,” he says. “After all, we reviewed the data on 50 different modalities. If patients have a positive attitude and participate in their care, there is much that can be done.”
The authors of the recommendations (which are less formal than guidelines) write that they are “not intended to be used in a ‘cookbook’ fashion, but rather to provide guidance based on clinical evidence and expert panel input.”
The aim is to provide rheumatologists, general practitioners and patients a guide to proven, effective treatments based on the best available evidence, says Marc C. Hochberg, MD, professor of medicine at the University of Maryland School of Medicine in Baltimore and chair of the ACR’s OA guideline committee.
The recommendations, which were published in the April issue of Arthritis Care & Research, were updated to take into account the latest studies and better ways to weigh medical evidence developed since the last recommendations were issued in 2000. Important new additions (aside from the hand OA recommendations) include recommendations on the use of glucosamine, chondroitin sulfate, opioids and topical nonsteroidal anti-inflammatory drugs, or NSAIDs.
To formulate the ACR recommendations, a panel of experts – including academic and practicing rheumatologists, primary care physicians, physiatrists, geriatricians, orthopaedic surgeons, and occupational and physical therapists – 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.
In cases where the panel determined evidence was high-quality – for example, because it was based on several randomized, controlled trials – the recommendation (either for or against) was rated “strong.” Weaker evidence – for example, because the benefits of a treatment did not clearly outweigh the potential risks, or because the quality of the studies was inferior – led to a “conditional” rating. And in cases where evidence was insufficient, the panel chose not to issue a recommendation.
Approval of the recommendations was consensus-based, requiring agreement among at least 75 percent of panel members.
Treatments for Hip and Knee OA
The panel issued a range of drug and non-drug recommendations for treating knee and hip OA. Two of the strongest are for land-based exercise or aquatic exercise and for weight loss when needed.
Sharon Kolasinski, MD, professor of medicine at Cooper Medical School in Camden, N.J., who was not involved in drafting the recommendations, says the emphasis on exercise is important.
“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,” she says. “No intervention can halt the progression of OA, but exercise and weight loss are particularly important [for quality of life].”.
A separate study published in the January 2011 issue of Arthritis Care & Research found that many doctors were not following standard-care guidelines when treating patients – for example moving straight to prescription medication and surgery instead of first recommending exercise and weight loss.
In terms of medications, no drug therapies receive strong support, but the panel conditionally recommends acetaminophen, oral NSAIDs, the synthetic opioid tramadol and corticosteroid joint injections.
For knee OA in patients older than 75 years old, the panel strongly recommends the use of topical rather than oral NSAIDs – a new addition to the recommendations. (Topical NSAIDs were first approved by the U.S. Food and Drug Administration in 2007.) Because they are applied to the skin, topicals are thought to cause less stomach bleeding and fewer other side effects than oral NSAIDs; people older than 75 are at higher risk for developing these complications.
For younger people at high risk of gastrointestinal side effects, the panel recommends the COX-2 inhibitor celecoxib, or Celebrex, which was designed to protect the stomach, or a traditional NSAID along with a stomach-protective drug, such as a proton-pump inhibitor, a class of drug that includes esomeprazole, or Nexium, or omeprazole, or Prilosec.
And for people who don’t respond to other treatments and aren’t candidates for joint replacement, the panel strongly endorses opioids such as hydrocodone, but cautions that doctors who prescribe them should follow guidelines established by the American Pain Society and the American Academy of Pain Medicine.
In one of its admittedly more controversial moves, the panel conditionally recommends against using chondroitin sulfate and glucosamine for knee and hip OA. The ACR withheld judgment on the supplements in 2000.
“The body of evidence from recent North American studies … failed to demonstrate efficacy for [these supplements] greater than placebo, so the panel felt the evidence did not support their use,” explains Dr. Hochberg, adding that forms of the supplements tested in the U.S. are different from those in Europe found to be safe and effective.
Although the recommendations for hip and knee OA were similar overall, they did diverge. For hip OA, there was insufficient evidence to recommend tai chi, acupuncture, TENS (transcutaneous electrical nerve stimulation) or intra-articular hyaluronate injections. However, for knee OA, all of these treatments were conditionally recommended.
A New Focus on Hand OA
In addressing hand OA for the first time, the panel made no strong recommendations because supporting evidence for various interventions was weak or insufficient.
Conditional recommendations for initial non-drug treatment 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.
Conditional drug recommendations 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, which is no longer recommended for knee and hip pain.
The authors of the recommendations write, “As new evidence continues to be developed, it is likely that these recommendations will need to be updated and/or revised.”
Dr. Kolasinski says she is encouraged that the updated ACR recommendations address long-neglected hand OA, which is debilitating for many people, and that there is an emphasis on exercise for knee and hip OA. Although, she says, “Over the last decade we haven’t made as much progress as we would like in pharmacological interventions in OA.”
Dr. Hochberg sees things differently. “It’s important for people to recognize that there are a lot of interventions available to them,” he says. “After all, we reviewed the data on 50 different modalities. If patients have a positive attitude and participate in their care, there is much that can be done.”
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