Osteoarthritis recommendations lack ‘granular guidance’ on exercise, weight loss

SAN DIEGO — Although most osteoarthritis experts agree that diet and exercise are critical to disease management, detailed guidance on either remain lacking, according to a presenter at the 2024 Congress of Clinical Rheumatology West.

“There is a long history of failed trials in osteoarthritis,” Amanda E. Nelson, MD, MSCR, RhMSUS, professor of medicine and adjunct associate professor of epidemiology at the University of North Carolina Gillings School of Global Public Health, told attendees.

“Education, exercise and weight loss are still key therapies,” she added.

According to Nelson, guideline documents from the American College of Rheumatology, EULAR and other organizations all generally agree that these interventions are most effective for patients with OA. However, she suggested that they are frequently short on details.

“In the ACR guidelines, weight loss is strongly recommended,” Nelson said. “But they do not say how to lose the weight, and they do not say how much weight to lose. There is no granular guidance around weight loss.”

She additionally argued that rheumatologists should consult obesity management guidelines for more granular evidence and recommendations.

According to Nelson, one important difference between those documents and documents from rheumatology societies is a lower threshold for the use of anti-obesity medications.

“Most of these patients would benefit from more aggressive obesity management than our guidelines suggest,” she said.

Many patients have used bariatric surgery to a “big effect,” Nelson added. She also noted that semaglutide (Novo Nordisk) has been associated with improved pain based on the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) scale.

However, Nelson acknowledged that many in the rheumatology community may be unfamiliar with relatively new weight loss medications such as semaglutide. Consequently, they may be reticent to use them in clinical practice.

Nelson nonetheless suggested that these drugs could have significant benefit for patients with OA who have struggled with other approaches, and that rheumatologists should investigate these medications further.

“People have tried to lose weight,” she said. “It is a very hard thing to do. It is a lifestyle thing that they have to do forever.”

Regarding exercise, Nelson noted that many patients are told that they should exercise, but are provided with few additional instructions.

“Another problem is how we work on this with our patients,” she said.

Formally prescribing movement can help, according to Nelson.

“I give a walking prescription, the idea being that this is part of your treatment,” she said. “This is a prescription. You need to do this for your health.”

When providing these prescriptions, rheumatologists should consider each patient’s activity level and tailor exercise regimens accordingly.

“If we are starting from the couch, then moving off the couch is the first step,” Nelson said. “You do not have to save the world in one day.”

The goal should be at least 30 minutes daily of walking or other exercise, 5 days a week, according to Nelson. Enlisting other providers can also be beneficial.

“PT is grossly underutilized in osteoarthritis,” she said. “We need to use it to try to help some of our patients.”

Ultimately, according to Nelson, ongoing education for both weight loss and exercise can only help, considering how many providers fail to discuss these topics with their patients.

“There is a sense of abandonment,” she said. “It is helpful to explain the processes. We need to give them better options.”