What is the initial management for patients with arthrosis, specifically osteoarthritis?

Initial Management of 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 Interventions (First-Line)

Exercise Therapy

• Strongly recommended for all OA patients 2, 1
• Types of recommended exercise:
  • Aerobic/cardiovascular exercise
  • Resistance/strengthening exercises
  • Flexibility exercises
  • Neuromotor exercises 1, 3
• Exercise should be tailored to physical function and can be delivered through:
  • Individual or group sessions
  • Supervised or unsupervised programs
  • Land-based or aquatic settings 1

Weight Management

• Weight loss strongly recommended for overweight/obese patients 1
• Even modest weight loss can significantly improve symptoms and function 1

Education and Self-Management

• Provide information about OA and counter misconceptions
• Teach self-management strategies
• Include behavioral techniques when lifestyle modifications are needed 1

Physical Modalities

• Local heat or cold applications
• Transcutaneous electrical nerve stimulation (TENS)
• Manual therapy in combination with supervised exercise 2, 1
• Assistive devices:
  • Walking aids
  • Appropriate footwear
  • Braces or joint supports 1

Pharmacological Interventions (When Needed)

First-Line Pharmacological Options

• Knee and Hand OA:
  • Acetaminophen (up to 4,000 mg/day)
  • Topical NSAIDs 2, 1
• Hip OA:
  • Acetaminophen
  • Oral NSAIDs 1

Second-Line Pharmacological Options

If inadequate response to first-line options:

• Oral NSAIDs:

  • Use lowest effective dose for shortest time
  • Examples: Ibuprofen (400-800 mg TID or QID) 4 or Naproxen (375-500 mg BID) 5
  • For patients ≥75 years: Prefer topical NSAIDs over oral NSAIDs 2, 1
  • For patients with GI risk factors: Use COX-2 selective inhibitor or non-selective NSAID with a proton pump inhibitor 2

• Intra-articular Corticosteroid Injections:

  • For moderate to severe pain 2
  • Provides short-term relief (4-8 weeks) 6

• Tramadol:

  • For patients who cannot take NSAIDs or have inadequate pain relief 2

Algorithmic Approach to OA Management

1. Initial Assessment:

   • Confirm OA diagnosis
   • Assess pain severity, functional limitations, and impact on quality of life
   • Identify comorbidities that may affect treatment choices

2. Start Core Treatments for All Patients:

   • Structured exercise program
   • Education on self-management
   • Weight loss if overweight/obese

3. Add First-Line Pharmacological Treatment if Needed:

   • Knee/Hand OA: Acetaminophen or topical NSAIDs
   • Hip OA: Acetaminophen or oral NSAIDs

4. If Inadequate Response, Progress to:

   • Switch to or add oral NSAIDs (if not already using)
   • Consider intra-articular corticosteroid injections for moderate-severe pain
   • Add tramadol if NSAIDs contraindicated or ineffective

Important Considerations and Pitfalls

• Acetaminophen Safety: Counsel patients to avoid other products containing acetaminophen to prevent exceeding daily limits (4,000 mg) 1

• NSAID Risks: Consider higher GI, cardiovascular, and renal risks in elderly patients and those with comorbidities 1

  • For patients with GI risk: Use COX-2 selective inhibitor or add proton pump inhibitor
  • For patients with cardiovascular risk: Avoid NSAIDs if possible or use lowest dose for shortest time

• Common Pitfalls:

  • Overreliance on medications without implementing core non-pharmacological approaches
  • Failure to emphasize exercise as the foundation of treatment
  • Setting unrealistic expectations (treatments improve symptoms but are not curative)
  • Inadequate follow-up to ensure exercise adherence and program adjustment

• Supplements: Glucosamine and chondroitin are not recommended by the American College of Rheumatology for initial management 2, though some patients may benefit from them for moderate to severe OA 6

By implementing this comprehensive approach that prioritizes non-pharmacological interventions while judiciously using medications when needed, patients with osteoarthritis can experience significant improvements in pain, function, and quality of life.