American College of Rheumatology Releases Two New Publications Focused On Osteoarthritis and Sjögren's Syndrome
ATLANTA — The American College of Rheumatology has released new publications – updated (revised) recommendations aimed at improving the treatment of patients with osteoarthritis of the hand, hip and knee, and new classification criteria for Sjögren's syndrome.
Arthritis and other rheumatic diseases affect nearly 50 million Americans, and symptoms such as chronic pain, swelling and inflammation can mirror other illnesses. In addition, there are more than 100 rheumatic diseases that can affect any area of the body. The ACR creates and updates criteria sets and clinical practice guidelines to help researchers and clinicians identify and treat diseases that are often difficult to manage.
Rheumatic diseases such as osteoarthritis and Sjögren's syndrome are often complex and affect many aspects of the patient's life. Effective management requires the coordinated efforts of a diverse group of professionals including a rheumatologist.
"Rheumatic diseases can be challenging," says James O'Dell, MD; ACR president and rheumatology professor of internal medicine at the University of Nebraska Medical Center and the Omaha Veterans Affairs Medical Centers in Omaha, Neb. "Fortunately, rheumatologists are specially trained to recognize and treat rheumatic diseases and often partner with primary care physicians and other medical specialties to control rheumatic diseases with medications and non-pharmacologic therapies."
Management Recommendations Updated for Osteoarthritis
Patients with osteoarthritis should be treated with a combination of pharmacologic (medications) and non-pharmacologic therapies, and recommendations were made for the management of hand, hip and knee OA.
"Osteoarthritis is the most common form of arthritis affecting adults in the United States and is the principal cause of musculoskeletal pain, limitation in physical activity and reduction in health-related quality of life. It is important for all primary care providers and specialists taking care of patients with osteoarthritis to recognize that there is a lot that can be offered to the patient to reduce their pain and improve their function," says Marc C. Hochberg, MD, MPH; professor of medicine and epidemiology and public health, University of Maryland School of Medicine, Baltimore, and chair of the Task Force that developed the new ACR recommendations.
More than a decade has passed since the ACR released recommendations for the management of hip and knee OA. The updated recommendations were developed using a new methodology that included systematic literature reviews and the Grading of Recommendations Assessment, Development and Evaluation (called GRADE) approach – a system recognized for rating recommendations on quality, strength and transparency. Also new are recommendations for hand OA and the consideration of the values and judgments of both the patient and practitioner.
Both strong and conditional recommendations are highlighted as well as information about the safety and tolerability of new and existing therapies used to treat OA.
Strong recommendations were warranted when there was ample evidence of a large benefit with no or little risk. Conditional recommendations were warranted when there was only little or modest evidence and/or the benefit was small to moderate and did not greatly outweigh the risks. The recommendations also address suggestions for patients not responding to — or intolerant of — initial therapies and treatments as well as special circumstances (e.g., the patient has other chronic medical conditions).
Recommendations include:
Hand OA
- Non-pharmacologic recommendations:
- Conditionally recommend that health professionals should evaluate the ability to perform activities of daily living, instruct in joint protection techniques and provide splints for patients with trapeziometacarpal joint OA.
- Pharmacologic recommendations:
- Conditionally recommend that health professionals should use topical agents (capsaicin and/or NSAIDs), oral NSAIDs, and/or tramadol.
Knee OA
- Non-pharmacologic recommendations:
- Strongly recommend that patients with knee OA should participate in aerobic and/or resistance exercise, aquatic exercise and lose weight, if overweight.
- Conditionally recommend that patients with knee OA should participate in self-management programs, receive patient education and manual therapy in combination with supervised exercise.
- Pharmacologic recommendations:
- Conditionally recommend that patients with knee OA should use acetaminophen, oral NSAIDs, topical NSAIDs, tramadol or intra-articular corticosteroid injections. Conditional recommendations also included not using chondroitin sulfate, glucosamine and topical capsaicin. Opioid analgesics should be reserved for patients who have an indication for total joint replacement but are either unwilling to or have contraindications to undergoing the procedure.
Hip OA
- Non-pharmacologic recommendations:
- Strongly recommend that patients with hip OA should participate in aerobic and/or resistance exercise, aquatic exercise and lose weight, if overweight.
- Conditionally recommend that patients with hip OA participate in self-management programs and receive patient education and manual therapy in combination with supervised exercise.
- Pharmacologic recommendations:
- Conditionally recommend that patients with hip OA use acetaminophen, oral NSAIDs, tramadol or intra-articular corticosteroid injections. Conditional recommendations also included not using chondroitin sulfate and glucosamine. Opioid analgesics should be reserved for patients who have an indication for total joint replacement but are either unwilling to or have contraindications to undergoing the procedure.
Sjögren's Syndrome Criteria Embraces Multispecialty Approach
Sjögren's syndrome is an inflammatory rheumatic disease that can affect many different parts of the body, but most often affects the tear and saliva glands. Several medical specialties regularly provide treatment for this disease – including rheumatology, ophthalmology and oral medicine. While there have been previous classification criteria published, the current criteria are the first to be endorsed by the ACR.
"An important feature of the current criteria is the inclusion of objective tests related to oral, ocular and systemic manifestations of Sjögren's syndrome," says Dr. Lindsey Criswell, MD, MPH, DSc; professor of medicine and orofacial sciences and Division of Rheumatology chief at the University of California, San Francisco. "Thus, these criteria reinforce the multidisciplinary nature of the disease and underscore the importance of collaboration among these specialties in the assessment and management of this autoimmune disorder."
According to the new criteria, three medical specialties (rheumatology, ophthalmology and oral medicine) are required to determine a patient's disease status. Patients must meet at least two out of three criteria below to be classified as having Sjögren's syndrome:
- Blood test indicating presence of specific antibodies related to autoimmunity (anti-SS-A/B, or RF and ANA ≥ 1:320)
- Eye examination based on staining the surface of the eyes (using lissamine green and fluorescein) and scoring the level of dryness, which indicates an impaired ability to produce tears.
- Pathological examination of a biopsy of the minor salivary glands found in the lip (involving detection of lymphocytic foci) that indicates presence of autoimmune impairment of salivary function.
"Classification criteria based on objective tests are important to prevent misclassification of participants entering treatment trials on Sjögren's syndrome," says Caroline Shiboski, DDS, MPH, PhD; co-leader with Dr. Criswell of the Sjögren's International Collaborative Clinical Alliance. "It is important to avoid exposing misclassified individuals who don't have Sjögren's syndrome to new investigational drugs and any potential toxicity."
For more information on either of these publications, visit www.rheumatology.org
###
Editor's note: Publications were created to provide guidance and not for diagnostic purposes. Patients should talk to their rheumatologists to determine best course of treatment.
Headquartered in Atlanta, Ga., the American College of Rheumatology is an international professional medical society that represents more than 8,500 rheumatologists and rheumatology health professionals. Rheumatologists are internists or pediatricians who are qualified by training and experience in the diagnosis and treatment of arthritis and other diseases of the joints, muscles and bones. Over 50 million Americans — including nearly 300,000 children — suffer from the painful, disabling and sometimes fatal effects of arthritis and rheumatic diseases. The ACR's mission is to advance rheumatology, learn more by visiting www.rheumatology.org or follow ACR on Twitter at @acrheum.
