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Am Fam Physician. 2020;102(6):376-377

Clinical Question

What are the key approaches to managing patients with degenerative joint disease involving the hand, knee, or hip?

Bottom Line

This guideline underscores that we have multiple options to help patients with degenerative joint disease be more comfortable and functional, but we still have significant limitations based on the available evidence. For many of our patients, exercise, adaptive devices, and comfort measures will be the best approaches. (Level of Evidence = 5)

Synopsis

The American College of Rheumatology (ACR) convened a guideline development panel. Panel members, many of whom reported ties to industry, followed an explicit process of identifying key questions, conducting systematic literature reviews, and synthesizing recommendations based on the available data. The ACR had a panel of patients and an intraprofessional voting panel of rheumatologists, an internist, and occupational and physical therapists. On the basis of their own reviews of the available literature (rather than using systematic reviews conducted by other entities), the panel issued strong or conditional recommendations based on a 70% consensus among the voting panel members, typically according to the quality of the supporting data. The use of their own reviews rather than others is important in that some systematic reviews come to differing conclusions for some of their recommendations, such as intra-articular steroid injections. The panel made strong recommendations for a comprehensive approach that includes exercise, self-efficacy programs, weight loss, tai chi, and assistive devices (e.g., canes, tibiofemoral knee braces, thumb splints), as well as topical, oral, and intra-articular steroids (for knee and hip). The panel made conditional recommendations in favor of education, cognitive behavior therapy, and other forms of exercise. They made conditional recommendations in favor of taping, other types of splints and braces, acetaminophen, tramadol, duloxetine (Cymbalta), chondroitin (hand), topical capsaicin (knee), and acupuncture. They made strong recommendations against the use of transcutaneous electrical nerve stimulation (knee, hip), bisphosphonates, glucosamine, hydroxychloroquine (Plaquenil), methotrexate, biologics, platelet-rich plasma or stem cell injections, chondroitin (knee, hip), and intra-articular hyaluronic acid (hip). The panel made conditional recommendations against many other measures, including chondroitin (hand), hyaluronic acid injections (hand, knee), topical capsaicin (hand, hip), botulinum toxin, prolotherapy, colchicine, nontramadol opioids, fish oil, vitamin D, massage, and wedged insoles or modified shoes. Some of the negative recommendations were based on a lack of reasonable-quality evidence of benefit as opposed to an abundance of reasonable-quality evidence of the absence of benefit. Some of these areas will continue to evolve.

Study design: Practice guideline

Funding source: Foundation

Setting: Outpatient (any)

Reference:KolasinskiSLNeogiTHochbergMCet al2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol2020;72(2):220–233.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.

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