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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.

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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.


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An 87-year-old man is evaluated for a 6-month history of worsening right knee pain in the absence of trauma. He has bilateral knee osteoarthritis. The pain is worse with prolonged walking, and climbing stairs has become more difficult. He uses intermittent doses of acetaminophen and ibuprofen and applies diclofenac cream daily with some relief, but he continues to have significant pain with ambulation.

On physical examination, the patient has an antalgic gait but otherwise appears healthy. Vital signs are normal. There is marked crepitation in the anteromedial aspects of both knees. Small, cool, bilateral knee effusions are present. The medial and lateral joint lines of both knees are tender.

Weight-bearing radiographs reveal osteophytes in both knees; bone-on-bone joint-space loss in the medial and lateral compartments of the right knee is noted.

Q.

Which of the following is the most appropriate next step in management?

A corticosteroid injection into the right knee is indicated for this patient's osteoarthritic knee pain refractory to usual pharmacologic therapy. Intra-articular corticosteroids are particularly useful when a single joint is causing disproportionate pain relative to other joints and limitation of function. Successful corticosteroid joint injections may provide relief for up to 3 months.

Although glucosamine and chondroitin supplements are frequently used to treat osteoarthritis, studies evaluating their effectiveness have been mixed, particularly in patients with advanced disease and associated functional impairment.

Intra-articular viscosupplementation with hyaluronic acid is approved for treatment of osteoarthritis. However, a recent large systematic review and meta-analysis involving 89 randomized trials with more than 12,600 patients concluded that viscosupplementation for knee osteoarthritis provided only small and clinically irrelevant benefit. Additionally, hyaluronic acid injections appeared to significantly increase the risk of an acute flare of disease and were associated with other adverse effects, some of which were major. Based on these data, viscosupplementation in this patient would likely not be clinically effective in treating his symptoms and may increase his risk for worsening disease or other complications.

Low-dose opioids may have a role in advanced osteoarthritis by providing intermittent relief of refractory pain when used judiciously. However, in an older patient they carry a significant risk of cognitive impairment, falls, constipation, and urinary retention, and should be used only when other lower-risk treatment interventions have not been successful.

Key Point

  • A recent large systematic review and meta-analysis concluded that viscosupplementation with hyaluronic acid for knee osteoarthritis provided only small and clinically irrelevant benefit, appeared to significantly increase the risk of an acute flare of disease, and was associated with other adverse effects.
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