OARSI issues new version of knee osteoarthritis guidelines: The new version of the Osteoarthritis Research Society International (OARSI) guidelines for knee osteoarthritis (the previous version was issued in 2010) offers recommendations for weight reduction, education and exercise that differ significantly from the American College of Rheumatology (ACR) guidelines and the American Academy of Orthopaedic Surgeons (AAOS) guidelines issued in recent years. For example, the AAOS 2013 guidelines are eclectic regarding corticosteroids and acetaminophen knee injections, noting the lack of evidence; whereas the OARSI guidelines recommend the use of both drugs in the absence of associated comorbidities. Recent studies on steroid knee injections have shown that these drugs provide clinically significant short-term pain relief, significantly better than intra-articular hyaluronic acid injections. Meanwhile, hyaluronic acid knee injections provided longer-term relief in another study, a finding that led OARSI to make a recommendation similar to that of the ACR, classifying hyaluronic acid knee injections as “unclear.” AAOS opposes the use of hyaluronic acid, arguing that the drug lacks efficacy. OARSI’s recommendation was based on recent literature and the expert opinion of a 13-member review committee; most of the members were rheumatologists and most were from Europe. The committee voted on 13 nonpharmacologic and 16 pharmacologic treatments, categorizing them as “indicated,” “not indicated,” or “unclear” in terms of value for osteoarthritis of the knee (when evidence is lacking). evidence). Treatments judged to be “appropriate” for all patients with knee osteoarthritis included biomechanical interventions, corticosteroid knee injections, ground and water exercise, self-management and education, strength training, and weight management. Other treatments approved by the committee included acetaminophen, bath therapy (using mineral-rich hot water), topical capsaicin, walking sticks, duloxetine (Cymbalta), and, in the absence of contraindications, NSAIDs. A variety of treatments were judged “indeterminate”: acupuncture, avocado-soybean extract supplements, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid injections, opioids, wild rose hips, transcutaneous electrical nerve stimulation, and therapeutic ultrasound. The committee ruled risedronate (Actonel) and neuromuscular electrical stimulation as “not indicated” for osteoarthritis of the knee due to lack of evidence. The authors note that more recent findings have “heightened safety concerns about the use of treatments such as acetaminophen and opioids, while evidence supporting the use of treatments such as duloxetine, bath therapy, and ground-based exercise (e.g., tai chi) is strengthening. OARSI is more supportive of biomechanical interventions than other organizations, primarily because current research suggests that angular knee bracing and foot orthotics may improve function and reduce pain, stiffness and medication use. Another trial supports the use of wedge insoles as an alternative to valgus foot support. Similar to the ACR guidelines, and unlike the stronger recommendations of the AAOS, OARSI also supports oral NSAIDs for most patients, but is unsure if patients with heart disease and other related problems should also take oral NSAIDs. oARSI recommends concomitant use of proton pump inhibitors in cases of concern for gastric bleeding. They noted that naproxen appears to be superior to COX-2 inhibitors in terms of cardiovascular system safety. Diclofenac appears to have a higher chance of liver enzyme abnormalities, while celecoxib (Celebrex) appears to cause fewer ulcers but more cardiovascular problems. Topical NSAIDs are comparable in efficacy and less problematic than the oral form for osteoarthritis pain in the knee. Unlike the ACR, OARSI also considers topical capsaicin “for patients without associated comorbidities” and duloxetine “for most clinical subtypes,” although adverse events – nausea, fatigue, and other – are more common. -nausea, fatigue and others – and “the availability of more targeted therapies means that there is uncertainty about the suitability for patients with knee-only osteoarthritis with comorbidities. Expert commentary OARSI does not elaborate on how the various therapies work when used in combination. This is a common problem with all guidelines. The literature on combination therapy is so limited that the guidelines can only consider these therapies in isolation, yet in practice combination therapy is the usual practice in rheumatology practice. The OARSI guidelines have been heavily influenced by their European counterparts. This is not a bad thing, but American rheumatologists do not always treat their patients in the same way as their European counterparts. For example, diacerein is not available in the United States and avocado supplements are not popular. In addition, OARSI does not describe glucosamine sulfate and glucosamine hydrochloride separately. Glucosamine hydrochloride is clearly ineffective, and no consistent conclusion has been reached in the literature as to whether glucosamine sulfate is effective. I am also not sure that all intra-articular hyaluronic acids should be generalized; perhaps there are differences between them. In general, guidelines have little influence. There are too many guidelines available for clinicians to follow, and sometimes these guidelines are contradictory to each other.