What are the initial treatment recommendations for patients with osteoarthritis?

Initial Treatment Recommendations for Osteoarthritis

The core initial treatment for osteoarthritis should include exercise, education on self-management strategies, and weight loss for overweight patients, with pharmacological therapy beginning with acetaminophen or topical NSAIDs for knee/hand OA and oral NSAIDs for hip OA. 1

Non-Pharmacological Core Treatments

Exercise

• Strongly recommended as first-line therapy for all OA patients 1
• Types of recommended exercise:
  • Aerobic/cardiovascular exercise (land or water-based)
  • Resistance/strengthening exercises
  • Flexibility exercises
  • Neuromotor exercises (balance, coordination)
• Exercise should be of adequate dosage with progression tailored to physical function 1
• Mode of delivery can be:
  • Individual or group sessions
  • Supervised or unsupervised
  • Land-based or aquatic
  • Face-to-face or using digital technology

Education and Self-Management

• Provide information about OA and counter misconceptions 1
• Teach self-management strategies 1
• Include behavioral techniques when lifestyle modifications are needed 1
• Emphasize the importance of regular exercise and weight management 1

Weight Management

• Strongly recommended for overweight/obese patients 1
• Provide support to achieve and maintain weight loss
• Even modest weight loss can improve symptoms and function

Adjunctive Non-Pharmacological Approaches

Physical Modalities

• Local heat or cold applications 1
• TENS (transcutaneous electrical nerve stimulation) for selected patients 1
• Manual therapy in combination with supervised exercise 1

Assistive Devices

• Walking aids (canes, walkers) as needed 1
• Appropriate footwear with shock-absorbing properties 1
• Braces, joint supports, or insoles for biomechanical issues 1

Initial Pharmacological Management

For Knee OA

1. First-line options:

   • Acetaminophen (up to 4,000 mg/day) 1
   • Topical NSAIDs 1

2. If inadequate response:

   • Oral NSAIDs at lowest effective dose for shortest time 1
   • Intra-articular corticosteroid injections 1
   • Tramadol 1

For Hip OA

1. First-line options:

   • Acetaminophen (up to 4,000 mg/day) 1
   • Oral NSAIDs at lowest effective dose for shortest time 1

2. If inadequate response:

   • Intra-articular corticosteroid injections 1
   • Tramadol 1

For Hand OA

1. First-line options:

   • Acetaminophen 1
   • Topical NSAIDs 1

2. If inadequate response:

   • Oral NSAIDs 1
   • Intra-articular corticosteroid injections (for first CMC joint) 1

Important Considerations for NSAID Use

• For patients ≥75 years, prefer topical over oral NSAIDs 1
• For patients with GI risk factors, use either:
  • COX-2 selective inhibitor, OR
  • Non-selective NSAID with proton pump inhibitor 1
• Consider cardiovascular, renal, and hepatic risks 1, 2
• Use at lowest effective dose for shortest possible period 1, 2

Treatments NOT Recommended

• Glucosamine and chondroitin supplements 1
• Electroacupuncture 1
• Opioid analgesics (except tramadol) for initial management 1

Treatment Algorithm

1. Start with core treatments for all patients:

   • Exercise program
   • Education and self-management strategies
   • Weight loss if overweight/obese

2. Add first-line pharmacological therapy based on joint involvement:

   • Knee/Hand: Acetaminophen or topical NSAIDs
   • Hip: Acetaminophen or oral NSAIDs (with PPI if indicated)

3. If inadequate response after 2-4 weeks:

   • Switch to or add oral NSAIDs (if not already using)
   • Consider intra-articular corticosteroid injections for flare-ups
   • Add tramadol if pain persists despite above measures

4. Continuously reinforce non-pharmacological approaches throughout treatment

Pitfalls and Caveats

• Acetaminophen safety: Counsel patients to avoid other products containing acetaminophen to prevent exceeding daily limits 1
• NSAID risks: Higher GI, cardiovascular, and renal risks in elderly patients and those with comorbidities 1, 2
• Exercise adherence: Poor adherence is common; regular follow-up and reinforcement are essential 3, 4
• Unrealistic expectations: Clarify that while treatments can improve symptoms and function, they are not curative 1
• Overreliance on medications: Emphasize that non-pharmacological approaches are the foundation of treatment 1