What are the recommended medications for managing osteoarthritis?

Recommended Medications for Managing Osteoarthritis

Oral NSAIDs are the initial oral medication of choice for osteoarthritis treatment, regardless of anatomic location, and are recommended over all other available oral medications. 1

Pharmacological Treatment Algorithm

First-Line Therapy:

• For knee and hand OA: Start with paracetamol (acetaminophen) and/or topical NSAIDs 1
  • Paracetamol dosing: Up to 3g daily in divided doses 1
  • Topical NSAIDs applied directly to affected joints

Second-Line Therapy (if first-line inadequate):

• Oral NSAIDs (including COX-2 inhibitors) 1
  • Use at lowest effective dose for shortest possible time
  • First choice: either a standard NSAID (like ibuprofen, naproxen) or COX-2 inhibitor
  • Always prescribe with a proton pump inhibitor for gastroprotection 1

Third-Line Options:

• Duloxetine is conditionally recommended for knee, hip, and hand OA 1
• Opioid analgesics if other options insufficient or contraindicated 1
• Topical capsaicin for localized pain relief 1

Intra-articular Treatments:

• Corticosteroid injections for moderate to severe pain 1
  • Strongly recommended for knee and hip OA
  • Conditionally recommended for hand OA
  • Ultrasound guidance strongly recommended for hip injections 1

Important Considerations

Risk Assessment for NSAID Use:

• Assess individual risk factors including:
  • Age (elderly patients at higher risk)
  • Gastrointestinal history
  • Cardiovascular disease
  • Renal function
  • Concomitant medications (especially low-dose aspirin)

Medication-Specific Cautions:

1. NSAIDs: Monitor for GI, cardiovascular, and renal side effects 1, 2, 3

   • Ibuprofen may interact with aspirin's antiplatelet activity 2
   • Naproxen is indicated specifically for osteoarthritis 3

2. Paracetamol (Acetaminophen):

   • Regular monitoring for hepatotoxicity required for long-term use 1
   • Effect sizes in clinical trials are very small 1
   • Many patients find it ineffective as monotherapy 1

3. Opioids:

   • Reserve for when other options have failed
   • Balance pain relief against risk of dependence and side effects

Common Pitfalls to Avoid

1. Overreliance on paracetamol: While traditionally recommended as first-line, recent evidence suggests limited efficacy for most patients 1

2. Prolonged NSAID use without gastroprotection: Always prescribe with a proton pump inhibitor 1

3. Ignoring non-pharmacological approaches: Medications should supplement core treatments:

   • Exercise (muscle strengthening and aerobic fitness)
   • Weight loss if overweight
   • Appropriate patient education 1

4. Using glucosamine and chondroitin products: Not recommended due to insufficient evidence 1

5. Failure to tailor treatment to specific joints: Some treatments are more effective for specific joints (e.g., topical NSAIDs for knee and hand OA)

By following this evidence-based approach to medication selection for osteoarthritis, clinicians can optimize pain relief and functional improvement while minimizing adverse effects.