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Osteoarthritis Guidelines Take Balanced Approach to Therapy

Kate Traynor

New guidelines from the American College of Rheumatology (ACR) recommend both drug therapy and nonpharmacologic interventions for patients with osteoarthritis of the hand, hip, or knee.

In developing the guidelines, ACR enlisted a diverse group of practitioners to examine the scientific evidence and modernized the process for weighing that evidence.

The resulting document contains "strong" recommendations for interventions associated with large health benefits and little or no risk. Conditional recommendations are given for interventions associated with modest evidence for small benefits that did not greatly outweigh risks. And emphasis is given on incorporating patients' preferences and values into their treatment plans.

Mary Ann E. Zagaria, senior care consultant pharmacist and president of Norwich, New York-based MZ Associates Inc., which focuses on pharmaceutical care for seniors, called the guidelines a valuable resource for clinicians who care for older patients.

"This really will give pharmacists in all practice settings a very comprehensive set of recommendations," said Zagaria, who is a certified geriatric pharmacist.

The updated guidelines appear in the April 2012 issue of Arthritis Care and Research and replace recommendations that were released in 2000.

The previous version did not address osteoarthritis of the hand. Zagaria said she is pleased to have recommendations for the management of this sometimes-disabling condition.

"There are psychological and physical components to the disability. It really impairs them," she said of patients with hand osteoarthritis. "It's very distressing when you cannot perform a lot of [basic] functions with your hands."

All pharmacologic and nondrug interventions for hand osteoarthritis in the guidelines are conditional recommendations. Specific recommendations for the initial management of hand osteoarthritis include the use of topical capasaicin, trolamine salicylate, or other nonsteroidal antiinflammatory drugs (NSAIDs); oral NSAIDs; or tramadol. For patients 75 years of age or older, oral NSAIDs should be avoided in favor of topical agents.

"I like the fact that they included topical capasaicin and topical NSAIDs. These are approaches that, I believe, have been underutilized," Zagaria said.

She noted that clinicians should avoid recommending oral NSAIDs in patients age 75 or older because of their greatly increased risk for serious adverse gastrointestinal events from exposure to these medications.

Osteoarthritis is caused by aging and wear and tear on joints and is characterized by joint pain and stiffness. Nearly everyone who lives to age 70 will have some degree of osteoarthritis, which is the most common disorder affecting the joints, according to the National Institutes of Health.

Because osteoarthritis is irreversible, treatment of the condition focuses on relieving its symptoms. People with severe knee or hip osteoarthritis may ultimately require joint replacement to resolve their pain.

ACR conditionally recommends acetaminophen, oral or topical NSAIDs, tramadol, or intra-articular corticosteroid injections for the initial treatment of knee osteoarthritis. These recommendations are the same for hip osteoarthritis, except that topical NSAID therapy is not recommended.

If oral NSAIDs are used for the chronic treatment of hip or knee osteoarthritis in patients 75 years or older, ACR strongly recommends using either a cyclooxygenase (COX)-2-selective NSAID or a nonselective NSAID. If the patient has had bleeding in the upper gastrointestinal tract within the past year, ACR recommends the use of a COX-2-selective NSAID plus a proton pump inhibitor.

For any patient receiving oral NSAIDs for the chronic treatment of hip or knee osteoarthritis, clinicians should consider a concomitant proton pump inhibitor, according to the guidelines.

The document also advises clinicians to be aware that oral ibuprofen given concomitantly with low-dosage aspirin therapy may reduce the cardioprotective effect of the aspirin.

For both hip and knee osteoarthritis, ACR conditionally recommends that opioid therapy be reserved for patients who are candidates for joint replacement but are unable or unwilling to undergo the procedure.

Dominick P. Trombetta, associate professor of pharmacy practice at Wilkes University's Nesbitt School of Pharmacy in Wilkes-Barre, Pennsylvania, and a certified geriatric pharmacist, sees many joint-replacement patients in his practice and said he was pleased that ACR updated its guidelines.

"It's been long overdue. I think there have been a lot of changes in practice, with the emphasis in evidence-based medicine," he said.

Trombetta supports the use of nonprescription treatments for the initial management of osteoarthritis as described in the guidelines but said this can be unwelcome news to patients.

"Acetaminophen is still underutilized for initial treatment. No one wants to go to the doctor and hear, 'Try some Tylenol three times a day,'" Trombetta said.

None of the specific recommendations are new to those who treat patients with osteoarthritis, he said. But he believes that having authoritative recommendations provides validation for clinicians.

Trombetta said he appreciates that the recommendations promote the difficult task of balancing the benefits and harms of pharmacologic and nondrug treatments for osteoarthritis to achieve the best outcomes for individual patients.

"I think what most people want is to be independent and not have to rely on others," Trombetta said. "There's folks with knee osteoarthritis who can't get up, or it's really painful and they can't exercise comfortably. Or they can't participate with social activities because they are in so much pain."

He urged pharmacists to be aware of nondrug interventions for such patients.

"In my experience, the nonpharmacologic recommendations tend to be the most effective and yet the most underutilized recommendations to patients," he said. "The weight loss, exercise, tai chi. Those recommendations clearly cannot be overemphasized in their importance."

Nearly all of the strong recommendations in ACR's updated guidelines describe nonpharmacologic interventions. These include regular aerobic and strength-building exercise for patients with hip or knee osteoarthritis and weight loss for those who are overweight.

When possible, Zagaria said, the exercise recommendations should follow the Centers for Disease Control and Prevention's guidance on minimum physical activity levels for adults and older adults: 150 minutes of moderate aerobic exercise per week and strength training at least twice a week.

"I am an advocate of seniors exercising," she said. "Many people may not be aware of the fact that older adults really can benefit from exercise."

The guidelines are available at the ACR website,

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