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.”