Summary

2019 ACR/Arthritis Foundation guideline updating the 2012 recommendations for management of hand, hip, and knee osteoarthritis using GRADE methodology. Emphasizes multimodal, shared decision-making care with exercise, weight loss, and self-management as foundational, plus topical/oral NSAIDs and intraarticular glucocorticoids as primary pharmacologic options. Notable changes from 2012 include a stronger recommendation against glucosamine, recommendations against hyaluronic acid injections (conditional for knee/CMC, strong for hip), and against TENS, stem cell, and PRP injections.

Key Recommendations

Strongly recommend exercise (walking, strengthening, neuromuscular, or aquatic) for hand, hip, and knee OA — supervised programs are more effective.
Strongly recommend weight loss for overweight/obese patients with knee and/or hip OA, ideally combined with exercise.
Strongly recommend self-efficacy/self-management programs and tai chi for knee and/or hip OA.
Strongly recommend cane use and tibiofemoral knee bracing when OA significantly impacts ambulation, stability, or pain.
Strongly recommend hand orthoses (neoprene or rigid) for first CMC joint OA; conditionally recommend orthoses for other hand joints.
Oral NSAIDs are the mainstay and first-line oral pharmacotherapy for hand, hip, and knee OA — use lowest dose for shortest duration.
Topical NSAIDs strongly recommended for knee OA (try before oral NSAIDs); conditionally recommended for hand OA; not recommended for hip due to joint depth.
Strongly recommend intraarticular glucocorticoid injections for knee and hip OA (conditional for hand); use ultrasound guidance for hip injections.
Conditionally recommend acetaminophen, duloxetine, and tramadol — reserve for patients with NSAID contraindications or inadequate response.
Strongly recommend AGAINST glucosamine, bisphosphonates, hydroxychloroquine, methotrexate, TNF/IL-1 inhibitors, TENS, PRP, and stem cell injections for OA.
Strongly recommend AGAINST intraarticular hyaluronic acid for hip OA; conditionally against for knee and first CMC.
Conditionally recommend AGAINST non-tramadol opioids, colchicine, fish oil, vitamin D, chondroitin (knee/hip), modified shoes, wedged insoles, manual therapy added to exercise, and massage.

Thresholds & Doses

Weight loss ≥5% of body weight associated with symptom and functional improvement in knee/hip OA; benefits continue to increase with 5–10%, 10–20%, and >20% loss.
Acetaminophen maximum dosage 3 g daily in divided doses, with monitoring for hepatotoxicity with regular use.
70% Voting Panel consensus required to define recommendation strength under GRADE.
Self-management program sessions: typically 3 times weekly (range 2–6 times weekly) in reviewed studies.
Tramadol/opioids: RCT evidence is limited to ≤1 year; use lowest dose for shortest duration.

Citations

Results/Recommendations — Comprehensive management of OA — multimodal approach and shared decision-making framework
Table 1 / Physical, psychosocial, and mind-body approaches — exercise, weight loss, tai chi, bracing, orthoses, cane recommendations
Table 2 / Pharmacologic management — topical/oral NSAIDs, IA glucocorticoids, acetaminophen, duloxetine, tramadol
Pharmacologic management — Glucosamine and chondroitin sulfate sections — strong recommendation against (change from 2012)
Pharmacologic management — Intraarticular hyaluronic acid section — conditional against for knee/CMC, strong against for hip
Pharmacologic management — TNF inhibitors / IL-1 antagonists / PRP / stem cell sections — strongly recommended against
Figure 1 and Figure 2 — visual summary of recommended and not-recommended therapies
Reference 18 (Messier 2018) — dose-response for weight loss ≥5% in knee OA