New ACR guidance expands treatment choices for osteoarthritis

Clinical takeaway: For most patients with osteoarthritis, exercise, self-management, weight loss when appropriate, NSAIDs, and intra-articular glucocorticoid injections remain the cornerstones of care. New guidance supports considering GLP-1 receptor agonists for patients with knee OA and obesity and methotrexate for erosive hand OA in selected cases.

The American College of Rheumatology (ACR) has released a 2026 update to its osteoarthritis (OA) recommendations, emphasizing personalized, multimodal management of knee, hip, and hand OA through shared decision-making. The update revises the 2019 ACR/Arthritis Foundation guideline and incorporates new evidence on pharmacologic and nonpharmacologic therapies.

The strongest recommendations continue to focus on interventions with low toxicity and broad benefit, including exercise for knee and hip OA, weight loss for patients with overweight or obesity, topical and oral NSAIDs, and intra-articular glucocorticoid injections. Ultrasound guidance is strongly recommended for hip glucocorticoid injections.

Notably, the guideline introduces a new conditional recommendation for GLP-1 receptor agonists in patients with knee OA and obesity, to help achieve weight loss alongside diet and exercise. The panel also conditionally recommends methotrexate for erosive hand OA, reflecting emerging evidence in this difficult-to-treat subset of patients.

Additional conditional recommendations include duloxetine, acetaminophen, topical capsaicin for knee OA, hand orthoses, knee bracing, tai chi, yoga, cognitive behavioral therapy, acupuncture, and radiofrequency ablation in selected patients.

The guideline also reinforces recommendations against several therapies. Strong recommendations against platelet-rich plasma, stem cell injections, hydroxychloroquine, bisphosphonates, glucosamine and chondroitin supplements, TNF inhibitors, and IL-1 inhibition for hand OA reflect a lack of proven benefit or concerns about harms and costs. Opioids, hyaluronic acid injections, prolotherapy, colchicine, vitamin D, and fish oil are among the therapies conditionally recommended against.

"These updated recommendations recognize that there is no single treatment pathway that fits every person living with osteoarthritis," said lead author Dr. Sharon L. Kolasinski. "Our strongest recommendations continue to center on helping people build confidence in managing their condition, remaining physically active, and pursuing weight loss when appropriate."

What's changed

• New conditional recommendation for GLP-1 receptor agonists in patients with knee OA and obesity to support weight loss.
• New conditional recommendation for methotrexate in erosive hand OA.
• Recommendation direction changed for methotrexate, which is now conditionally recommended in erosive hand OA but conditionally recommended against in knee and hip OA.
• Recommendation direction changed for glucosamine/chondroitin preparations, now strongly recommended against.
• Continued emphasis on exercise, weight loss, NSAIDs, and glucocorticoid injections as foundational therapies.

Source: Kolasinski SL, et al. (2026 Sep 14) American College of Rheumatology. 2026 Update of the American College of Rheumatology Recommendations for the Management of Osteoarthritis of the Knee, Hip, and Hand