Shared decision-making, clinical judgment take priority where OA guidelines diverge
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Shared decision-making and clinical judgment are key to effectively managing osteoarthritis patients, especially when sets of osteoarthritis guidelines disagree on the best course of action, noted a speaker at the ACR State-of-the-Art Clinical Symposium.
Marc C. Hochberg, MD, MPH, head of the division of rheumatology and clinical immunology at the University of Maryland School of Medicine, framed his talk using a case patient, a 65-year-old woman with pain in her knees.
This patient had hypertension and diabetes and had battled weight for most of her life. After self-managing with over-the-counter acetaminophen and glucosamine, she visited a rheumatologist for an in-office visit. She was found to have bony enlargements without tenderness in both hands, bony enlargement with mild warmth in both knees, no soft tissue swelling — indicating no clinically important diffusion — positive patellar apprehension and moderate pain on motion.
The question, then, was raised of whether an imaging analysis would be necessary for this patient. “If yes, what modality?” Hochberg said.
Conventional radiograph is not necessary, according to Hochberg. He noted that it is possible to make a presumptive diagnosis of knee or hip OA solely based on history and physical exam. “Documentation supports this,” he said.
Ultrasound would be “clinically relevant” in this patient, according to Hochberg. “It could identify intra-articular infusion, which is present in the majority of patients with knee OA who have pain,” he said. “It would also help if considering an intra-articular injection, which we do under ultrasound.”
Magnetic resonance imaging is of “minimal or low value,” Hochberg added.
With that, Hochberg ran down some of the divergent areas between the American College of Rheumatology/Arthritis Foundation (ACR/AF) guidelines for OA patients, and those from the Osteoarthritis Research Society International (OARSI). He suggested that attendees consider the aforementioned case patient for each component of the guidelines.
While both documents require 70% agreement from the voting panel for a “strong” recommendation for or against a particular intervention, the ACR/AF required agreement from half of the voting panel for “conditional” recommendations, while OARSI required agreement of 26% or more of the panel for conditional recommendations.
Both organizations stipulate that shared decision-making between doctor and patient can take priority over recommendations if the evidence is weak or the “amount of benefit is judged to be marginal,” according to Hochberg. He added that both organizations allow for a “multimodal” approach to OA treatment using non-pharmacologic and pharmacologic interventions.
Regarding non-pharmacologic approaches, there is agreement among organizations that self-management, patient education, weight management and physical exercise are all excellent modalities of OA care. Exercise may be aerobic or resistance-based. “I recommend that patients start with aquatic exercise,” Hochberg said.
Tai chi and yoga are recommended, as well; there is also agreement that mindfulness approaches like cognitive behavioral therapy may also have utility in the OA setting.
However, the ACR conditionally recommends in favor of acupuncture for knee OA, while OARSI recommends against it. In addition, the ACR recommends against bracing for OA patients, while OARSI is “silent” on the matter, according to Hochberg.
While OARSI recommends in favor of massage therapy, the ACR recommends against it unless it is combined with an exercise regimen.
Turning to agreements and disagreements in pharmacologic therapy, both organizations call for topical NSAIDs in the first line before moving on to an oral NSAID.
“Both guidelines conditionally recommend duloxetine and corticosteroid injections,” Hochberg said.
A key area of disagreement pertains to acetaminophen. The ACR is conditionally for, while OARSI is conditionally against.
Conversely, the ACR is conditionally against hyaluronate intra-articular injections, while OARSI is conditionally for this intervention.
The ACR also conditionally recommends tramadol, while OARSI, at least in part due to the opioid epidemic, is conditionally against this intervention. “Tramadol is associated with lower incidence of serious adverse events, particularly falls and fractures,” Hochberg said.
Collapse
Hochberg MC. OA Practical Application of Guidelines and Current Controversies. Presented at: American College of Rheumatology State-of-the-Art Clinical Symposium. April 9-11, 2021 (virtual meeting).
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