Losing weight and engaging in low-impact aerobic exercise are the top recommendations of new guidelines for symptomatic osteoarthritis (OA) of the knee from the American Academy of Orthopaedic Surgeons.

The recommendations focus on nonsurgical therapies. Specifically, they urge clinicians to encourage patients with BMI >25 to lose at least 5% of their body weight and to begin or expand a low-impact exercise regimen.

“These two recommendations are very important because they allow patients to manage the progression of their OA,” comments John Richmond, MD, who chaired the guideline committee. “Losing weight has the highest potential to actually slow the progression of disease.”

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The committee’s report takes a dim view of a number of popular treatments. It recommends against using glucosamine and/or chondroitin sulfate or hydrochloride, prescribing custom foot orthotics, and aspirating the knee with a saline injection.

“Current science shows us that just washing out the joint does not decrease the patient’s OA symptoms and can expose the patient to additional risk,” Dr.  Richmond states.

The guidelines cite insufficient evidence for a neutral stance on acupuncture, intra-articular hyaluronic acid, and braces, although they do suggest patellar taping for pain relief and improved function.

Other pain-management strategies include three analgesic options: acetaminophen <4 g/day, an unspecified amount of a nonsteroidal anti-inflammatory drug (NSAID), or a course of intra-articular corticosteroids.

For patients with a GI risk, the guidelines recommend clinicians choose among up to acetaminophen 4 g/day, topical NSAIDs, nonselective oral NSAIDs plus a gastro-protective agent, or COX-2 inhibitors. Risk factors include age >60 years, a history of peptic ulcers or of GI bleeding, concurrent use of corticosteroids and/or concomitant use of anticoagulants.

The complete report and supporting materials are available online.