What is the best approach for managing moderate osteoarthritis (OA) in both knees?

From the Guidelines

The best approach for managing moderate osteoarthritis in both knees involves a combination of non-pharmacological and pharmacological interventions, with a strong recommendation for exercise, weight loss, and topical NSAIDs, as supported by the 2019 American College of Rheumatology/Arthritis Foundation guideline 1.

Key Components of Management

• Weight management: prioritizing weight loss for patients who are overweight or obese to reduce knee pressure and improve function
• Regular exercise: low-impact activities like swimming, cycling, or walking for 30 minutes most days to maintain joint mobility and strengthen supporting muscles
• Physical therapy: focusing on quadriceps and hamstring strengthening to improve stability and reduce pain
• Medication: starting with acetaminophen for mild pain, progressing to NSAIDs like ibuprofen or naproxen for more significant pain and inflammation
• Topical NSAIDs: using diclofenac gel for localized relief with fewer systemic side effects
• Assistive devices: utilizing knee braces or walking aids to reduce joint stress
• Intra-articular injections: considering corticosteroid injections for flare-ups, limited to 3-4 injections yearly

Considerations for Treatment

• Patient preferences and access to exercise programs should be considered when developing an exercise plan
• Self-efficacy and self-management programs can enhance the effectiveness of exercise programs
• The choice of interventions may vary over the course of the disease or with patient and provider preferences, and is optimally arrived at through shared decision-making
• The availability, accessibility, and affordability of some interventions may vary, but many communities offer free self-efficacy and self-management programs

Evidence-Based Recommendations

• The 2019 American College of Rheumatology/Arthritis Foundation guideline provides strong recommendations for exercise, weight loss, self-efficacy and self-management programs, tai chi, cane use, and topical NSAIDs for knee OA 1
• The guideline also provides conditional recommendations for balance exercises, yoga, cognitive behavioral therapy, and other interventions
• The evidence supports a multimodal approach to managing moderate osteoarthritis in both knees, addressing both symptom management and functional improvement, and potentially slowing disease progression while improving quality of life 1

From the FDA Drug Label

In patients with osteoarthritis, the therapeutic action of naproxen has been shown by a reduction in joint pain or tenderness, an increase in range of motion in knee joints, increased mobility as demonstrated by a reduction in walking time, and improvement in capacity to perform activities of daily living impaired by the disease

The best approach for managing moderate osteoarthritis (OA) in both knees may include the use of naproxen, which has been shown to reduce joint pain and tenderness, increase range of motion, and improve mobility.

• Key benefits of naproxen in OA management include:
  • Reduction in joint pain or tenderness
  • Increase in range of motion in knee joints
  • Increased mobility
  • Improvement in capacity to perform daily activities 2

From the Research

Management of Moderate OA in Both Knees

The management of moderate osteoarthritis (OA) in both knees requires a multi-faceted approach, incorporating both non-pharmacological and pharmacological treatment modalities.

• Non-pharmacological therapies include:
  • Patient education
  • Lifestyle modification
  • Weight reduction
  • Regular exercise
  • Physiotherapy
  • Use of orthopaedic appliances (canes, insoles, braces) 3
• Pharmacological treatment includes:
  • Non-opioid or opioid analgetics
  • Non-steroidal anti-inflammatory drugs or coxibes
  • Intra-articular glucocorticoids
  • Glucosamin, chondroitin sulphate, and hyaluronic acid, which are safe and provide symptomatic relief, although their therapeutic effects remain uncertain 3

Lifestyle Changes

Lifestyle changes, such as exercise therapy and weight reduction, are gaining increasing recognition in the management of OA, and are now given priority over pharmacological therapies in most guidelines 4.

• Exercise therapy can help improve joint mobility and reduce pain
• Weight reduction can help reduce the load on the joints and slow down disease progression
• Footwear and orthotics can also play a role in managing OA symptoms 4

Patient and Provider Interventions

Patient and provider interventions, such as combined patient and provider interventions, can also be effective in managing OA 5.

• These interventions can include physical activity, weight management, and cognitive behavioral pain management
• Provider interventions can include provision of patient-specific recommendations for care, based on evidence-based guidelines

Pain Management

Pain management is a crucial aspect of OA management, and can be achieved through a variety of nonoperative options, including:

• Activity modification
• Therapy
• Weight loss
• Nonsteroidal anti-inflammatory drugs
• Shoe orthotics
• Bracing
• Injections 6

Prevention Strategies

Prevention strategies, such as identifying and modifying risk factors, can also play a role in managing OA 7.

• Joint injury, obesity, and impaired muscle function are modifiable risk factors that can be addressed through primary and secondary prevention strategies
• Personalized prevention approaches can help maximize adherence to and persistence with treatment regimes.