Evolution of the Osteoarthritis Guidelines with a Focus on Over-the-Counter Treatment Options

Abstract Title: Evolution of the Osteoarthritis Guidelines with a Focus on Over-the-Counter Treatment Options

Background: Osteoarthritis (OA) is the most common type of arthritis. It is characterized by pain and stiffness in the affected joints, which lead to reduction in function and mobility that can negatively impact quality of life. Pharmacists play a key role in OA management, particularly with the recommendation of over-the-counter (OTC) products. Treatment of OA includes nonpharmacological options, such as exercise, as well as pharmacological options including both OTC and prescription products.

Purpose/Objectives: The American College of Rheumatology (ACR) is a leader in the development of OA guidelines that evaluate treatment options for OA of the hands, hips, and knees. The ACR OA guidelines serve as a tool for healthcare providers in selecting appropriate therapy for the management of OA. The current management of OA remains focused on relieving symptoms and improving quality of life. The ACR OA guideline recommendations have evolved over time, as new data have become available. The objective was to evaluate the evolution of the ACR OA Guideline recommendations for use of pharmacologic treatment options over the last 30 years, with a focus on OTC products to provide valuable information to primary care professionals as front-line health care providers.

Method: A literature search was conducted for ACR OA Guidelines published in the last 30 years. The guidelines identified were evaluated for change in treatment ranking over time with a focus on the pharmacological options, particularly the OTC products. Ranking categories included strongly recommended, conditionally recommended, strongly against, conditionally against. Five ACR guidelines, published in the last 30 years were identified: 1995, 2000, 2009, 2012, and 2019. Nonpharmacological treatment options were included in all of the ACR guidelines and were recommended to be utilized in parallel with pharmacological treatment options.

Results: Oral NSAIDs remain a mainstay in the treatment of OA and were strongly recommended in 2019. Topical NSAIDs were added in the 2012 ACR guidelines and are now strongly recommended for knee OA ahead of oral NSAIDs. Reviewers conditionally recommend capsaicin for knee OA. Glucosamine/chondroitin, and methylsalicylate have dropped in ranking. Acetaminophen has dropped in ranking and is now only conditionally recommended for OA. Prescription oral NSAIDs and glucocorticoid injections have increased their ranking to strongly recommended. Non-tramadol opioids and hyaluronic acid injections have dropped in ranking and are now recommended against. Tramadol and duloxetine are conditionally recommended for OA.

Conclusions: While these guidelines provide general treatment recommendations, OA management should be patient specific, underscoring the importance of patient engagement with healthcare providers. Primary care professionals, especially those in the community setting play a pivotal role as they are the front-line healthcare providers working closely with patients and are often asked for their professional recommendations in OTC medication selection. As the ACR guidelines continue to evolve, it is critical for primary care professionals to be aware of the updates in treatment recommendations to better serve their patients.

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