Clinical Guidelines from ACP

Featured Clinical Guideline

Dietary and Pharmacologic Management to Prevent Recurrent Nephrolithiasis in Adults

Full text

Recent Guidelines Topics from ACP

Nonsurgical Management of Urinary Incontinence in Women

Full text
View ACP Guidelines on your smartphone. Mobile

ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

Access all Guidelines

Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


Of Interest and Note...

Online High Value Cases
  • Online High Value Cases: A series of High Value Care case studies are available for free to help clinicians understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care that improves health and eliminates wasteful practices.
  • ACP's Mobile Resources include a variety of applications, mobile web resources, and mobile documents to support your clinical practice.

A 59-year-old man is evaluated during a follow-up visit for knee osteoarthritis. He stands for most of the day at work, and his knees are very painful by the afternoon. He reports no joint locking, recent trauma, or twisting injury. Acetaminophen has not improved his symptoms, and as-needed ibuprofen and naproxen cause significant heartburn. History is notable for prediabetes and hypertension treated with combination lisinopril-hydrochlorothiazide.

On physical examination, blood pressure is 144/90 mm Hg, and pulse rate is 76/min. BMI is 30. The right knee is slightly warm with crepitus and mild anterior joint line tenderness. The left knee has crepitus without warmth. There is no laxity, and provocative compression does not produce pain or catching in either knee.

A topical NSAID is prescribed for use on both knees.

Q.

Which of the following is the most appropriate additional therapy for this patient?

Intensive exercise plus diet to achieve a 10% weight loss is appropriate for this patient who has knee osteoarthritis and is obese. The 18-month Intensive Diet and Exercise for Arthritis (IDEA) trial demonstrated that an exercise and diet plan to achieve a 10% weight loss in sedentary obese or overweight patients with knee osteoarthritis (age >55 years) improved compressive force, serum interleukin-6 levels, the intensity of pain, and quality of life more than exercise or diet alone. Patients in the exercise-only group lost less weight (1.8 kg [4.0 lb]) than patients in the diet-only group (8.9 kg [19.6 lb]) or the diet plus exercise group (10.6 kg [23.4 lb]). Diet consisted of 800 to 1000 kcal/d, and exercise was 3 hours per week (1 hour x 3 days). Of the participants, 88% completed the study. Although long-term outcomes of diet and weight loss programs are uncertain, this easily understood trial is worth discussing with patients.

Surgical interventions for treatment of osteoarthritis are reserved for patients who have had an inadequate response to pharmacologic and nonpharmacologic treatment. Additionally, arthroscopy with joint lavage has not been shown to be superior to closed joint lavage; the latter may be helpful in selected patients with refractory osteoarthritis. It is therefore an inappropriate treatment for this patient.

The effectiveness of transcutaneous electrical nerve stimulation (TENS) for osteoarthritis has not been established; several small clinical trials have produced conflicting results.

Ultrasound therapy of the joints is intended to heat the deeper connective tissues and possibly increase their extensibility with improvement in joint range of motion and decreased pain associated with degenerative change. However, clinical trials have not demonstrated a benefit, and ultrasound therapy is not recommended as a treatment for osteoarthritis.

Key Point

  • The Intensive Diet and Exercise for Arthritis (IDEA) trial demonstrated that exercise and diet to achieve a 10% weight loss in older, overweight/obese patients with knee osteoarthritis improved measures of pain, inflammatory markers, and quality of life better than exercise or diet alone.
ACP Clinical Shorts
An affordable and convenient way to earn MOC points and CME credit on the go.
Selected ACP Member Benefits
ACP JournalWise
ACP JournalWise

Online and optimized for mobile use, ACP JournalWise alerts you to the highest quality, most clinically relevant new articles in your preferred areas of specialty and with a frequency that you select.

Begin Search | Learn More

ACP Smart Medicine
ACP Smart MedicineSM

Authoritative, evidence-based guidance to improve clinical care. Earn free CME credit using ACP's new clinical decision support tool.

Sign In | Learn More

In the Clinic
In the Clinic

Evidence-based answers to frequently asked questions about screening, prevention, diagnosis, and therapy for common clinical conditions. Plus, downloadable slide sets to improve quality of care are available free to members.

In the Clinic | Access Slide Sets
Clinical Multimedia