The osteoarthritis treatment ‘fads’ that don’t work, GP guidelines
GPs have rubbished popular and “fad” treatments for osteoarthritis (OA), including opioids, acupuncture, glucosamine, stem cell therapy, insoles and surgery in new national guidelines aimed at helping millions of older Australians with the chronic condition.
The Royal Australian College of General Practitioners’ (RACGP) new guide for managing hip and knee OA strongly warned against surgeries such as knee arthroscopy, meniscectomy and cartilage repair.
Released on Wednesday, the guidelines championed no-drug, non-surgical options including weight loss, exercise and cognitive behavioural therapy (CBT).
The GP guidelines strongly recommended against using opioids, doxycyline, interleukin-1 inhibitors and stem cell therapies for OA, citing the low or very low quality of evidence supporting their use.
Complementary and alternative therapies that “should not be offered” included glucosamine, vitamin D and acupuncture, according to guidelines developed by a working group of rheumatology, orthopaedic surgery, GP, exercise and sports medicine specialists and Medibank clinical advisors.
“OA is a really hard and terrible illness for people to have,” RACGP president-elect Dr Harry Nespolon said.
“The problem is most of the treatments we’ve got are pretty poor, so naturally people go looking for any treatment that might help. But really they’d be better off spending their money on something else.
“Glucosamine is a classic example. People take it year after year but there’s no good evidence that it changes the course of OA.”
Australia’s ageing population and rising obesity rates are expected to drive up OA rates to an estimated 3.1 million by 2030 – 12 per cent of the total population.
There were also “conditional” recommendations against a suite of non-drug treatments including therapeutic ultrasound, shockwave and laser therapies, cold therapy.
Other products given the “conditional” thumbs down – indicating uncertainty over harm versus benefit of a treatment due to low or very low-quality evidence – included footwear marketed to OA sufferers, bisphosphonates, anti-nerve growth factor and omega 3 fatty acids.
A lack of high-quality evidence meant the college could make no recommendations for a range of other products, including shock-absorbing insoles, arch supports, electromagnetic or shortwave therapy, non-steroidal anti-inflammatory creams, collagen, avocado, soybean, turmeric and pine bark extract.
“Turmeric is all the rage … the latest fad,”Dr Nespolon said.
Sydney Orthopaedic surgeon Professor Ian Harris agreed the treatments were “a waste of money”.
“None of those are useful at all,” he said.
The guidelines also took aim at unnecessary and costly imaging, stipulating ultrasound, MRI and CT scans are not needed to diagnose OA and can lead to harmful interventions.
The College’s strong anti-surgery stance for OA -unless patients show signs of “locked knee” – supports recommendations from Australia’s peak body for rheumatologists warning doctors against arthroscopic knee surgery for patients with OA, especially if they were over 55 years old.
A growing body of evidence suggests these surgeries are at best placebo and at worst put patients at risk of serious complications.
The new guidelines instead recommended regular exercise and managing weight to relieve pain and improve function for people with OA.
Overweight or obese patients should aim to lose a minimum of 5-7.5 per cent of their body weight, according to the guidelines endorsed by the National Health and Medical Research Council.
It also strongly recommended muscle strengthening exercises including walking, Tai Chi, as well as stationary cycling and hatha yoga.
Dr Nespolon said every patient needed to be assessed as individuals but exercise was the new treatment “front-runner” ahead of invasive surgeries and medications.
“It is alarming how many surgeries may have been completed unnecessarily and with little gain,” Dr Nespolon said.
“Medication and surgery may still be used in serious cases [such as patients needing knee or hip replacements], but many cases can be assisted with diet and lifestyle changes.”
The guidelines also recommended CBT for some people in combination with exercise, heat packs, hot water bottles, using a cane or walker, depending on the patient.
Overall, the robustness of the evidence backing OA treatments was lacking, with most recommendations based on ‘low’ or ‘very low’-quality evidence.
But exercise and weight management were low-risk interventions that had overall health benefits as well as yielding some improvement for OA symptoms, Dr Nespolon and Professor Harris said.