What are the management options for knee osteoarthritis (OA)?

From the Guidelines

Management of knee osteoarthritis should prioritize a comprehensive approach combining non-pharmacological and pharmacological interventions, with strong recommendations for exercise, weight loss in overweight patients, self-efficacy and self-management programs, tai chi, cane use, and topical NSAIDs for knee OA, as well as oral NSAIDs and intraarticular glucocorticoid injections. This approach is based on the most recent and highest quality evidence available, including the 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee 1.

Key non-pharmacological interventions include:

• Regular exercise, such as aerobic, aquatic, and/or resistance exercises, which can help strengthen muscles supporting the knee joint and improve range of motion
• Weight loss for overweight patients, as each pound lost reduces knee load by four pounds
• Self-efficacy and self-management programs to enhance patient education and engagement in their care
• Tai chi for its benefits in improving balance and reducing pain
• Cane use to reduce joint stress and improve mobility

Pharmacological interventions may include:

• Topical NSAIDs, such as diclofenac gel, for their efficacy in reducing pain and inflammation in knee OA
• Oral NSAIDs, like ibuprofen or naproxen, for their stronger anti-inflammatory effects, although they carry gastrointestinal and cardiovascular risks
• Intraarticular glucocorticoid injections for temporary relief of acute flares
• Acetaminophen as a first-line oral medication for pain management, with NSAIDs considered for patients unresponsive to acetaminophen

Additionally, assistive devices such as knee braces, walking canes, and appropriate footwear can help reduce joint stress and improve mobility. For severe cases unresponsive to conservative measures, surgical options like arthroscopy, osteotomy, or knee replacement may be considered. The choice of interventions should be tailored to the individual patient's needs, preferences, and disease severity, with a focus on minimizing harm and maximizing benefit 1.

From the FDA Drug Label

After 13 weeks of treatment, patients taking duloxetine delayed-release capsules had significantly greater pain reduction than patients taking placebo. The efficacy of duloxetine delayed-release capsules in chronic pain due to osteoarthritis (OA) in adults was assessed in 2 double-blind, placebo-controlled, randomized clinical trials of 13-weeks duration (Study OA-1 and Study OA-2).

The management options for knee osteoarthritis (OA) include the use of duloxetine delayed-release capsules.

• The recommended dose is 60 mg once daily, with an option to increase to 120 mg once daily for patients with sub-optimal response to treatment.
• Pain reduction is a significant benefit of using duloxetine delayed-release capsules in patients with knee OA, as shown in Study OA-1 2.
• However, results may vary, as Study OA-2 did not show a significantly greater pain reduction compared to placebo.

From the Research

Management Options for Knee Osteoarthritis (OA)

The management of knee OA involves a range of options, from conservative non-pharmacological approaches to surgical interventions.

• Conservative Non-Pharmacological Management: This approach includes patient education, physical and occupational therapy, weight management, and exercise [(3,4,5)]. According to 5, the International Guidelines recommend exercise, education, and weight management as the first-line conservative treatment for patients with knee OA.
• Pharmacological Management: Pharmacologic therapy includes non-opioid oral and topical analgesics, and NSAIDs for patients who are unresponsive to non-pharmacologic modalities 3. Injections, such as intraarticular steroid injections, may also be used [(3,6)].
• Surgical Management: Surgical options include arthroscopy, cartilage repair, osteotomy, and knee arthroplasty [(7,4,6)]. The choice of surgical procedure depends on factors such as the location and stage of OA, comorbidities, and patient symptoms 7.
• Lifestyle Changes: Lifestyle changes, such as weight loss, are also important in the management of knee OA 6.

Factors Influencing Management Choices

The choice of management option depends on several factors, including:

• Severity of Symptoms: Patients with mild symptomatic OA may be managed with conservative non-pharmacological approaches, while those with severe symptoms may require more aggressive management, including surgical interventions 3.
• Patient Characteristics: Patient characteristics, such as age, comorbidities, and level of physical activity, also influence management choices [(7,5)].
• Barriers and Facilitators: Barriers to referral to exercise, such as patient disinterest, and facilitators, such as the importance of mentioning exercise despite short consultation time, also play a role in management choices 5.