Yoga, tai chi and topical NSAIDs are the first line treatments for people with hip and knee OA according to the latest OARSI guidelines.

But recommendations for intra-articular hyaluronic acid in OA add a note of controversy to the newly-published update to 2014 guidelines released by the Osteoarthritis Research Society International (OARSI).

Developed by an international working group based on evidence from over 400 RCTs, the latest guidelines recommend non-drug approaches such as exercise, education and diet as the ‘core’ treatments for hip, knee and polyarticular OA.

They give strong recommendations for topical NSAIDs (Level 1A) followed by conditional recommendations for oral non-selective NSAIDs, and COX-2 inhibitors (Level 1B). In a new development, treatments are recommended based on an algorithm specifically tailored to the presence of co-morbidities such as GI and cardiovascular disease.

Recommendations are made for intra-articular corticosteroids and hyaluronic acid, particularly where patients have co-morbidities such as cardiovascular disease where NSAIDs are not recommended.

Some non-drug treatments such as aquatic exercise are downgraded compared to previous guidelines. Likewise, duloxetine is downgraded and now only recommended for patients with widespread pain/depression.

Advice on paracetamol is now against its use in OA, and the use of oral and transdermal opioids is strongly not recommended.

The guidelines recommend against use of complementary therapies in OA, including acupuncture, topical capsaicin and balneotherapy and also against the use of nutraceuticals glucosamine and chondroitin.

However there is a conditional recommendation in favour recommendations for some complementary therapies such as massage, avocado soybean unsaponifiabales and curcuminoid formulations

The authors emphasised that the guidelines were developed independent of industry funding and were intended to be more patient centred.

Commenting on the update, Professor David Hunter, of the University of Sydney’s Institute of Bone and Joint Research, said the new guidelines were notable for including consideration for co-morbidities.

However he noted that many of the recommendations relied on expert consensus because evidence was lacking for many of the statements made.

“The position taken on steroids is a little surprising, given increasing recent evidence about the deleterious effects of repeat corticosteroid injection. The advocacy for hyaluronic acid is inconsistent with other guidelines,” he told the limbic.

He also questioned whether the recommendations would be adopted by clinicians since the panel contained a large number of academics who see few if any patients.

“Potentially as a reflection of this, my broad interpretation of the guidelines is that they are unwieldy and complicated and despite the development of an algorithm that in itself is not immediately transparent for a naive reader nor a consumer audience.

“As a consequence I wonder how widely these will be disseminated or implemented.”