What are the initial treatment recommendations for patients with osteoarthritis?

Initial Treatment Recommendations for Osteoarthritis

The initial treatment approach for osteoarthritis should prioritize non-pharmacological interventions, particularly structured exercise programs and weight management, before advancing to pharmacological options. 1

Non-Pharmacological Interventions (First-Line)

Exercise Therapy

• Implement a structured exercise program that includes:
  • Specific muscle strengthening (quadriceps and hip muscles)
  • Aerobic exercise (3-5 times weekly for 30 minutes)
  • Stretching and flexibility exercises 1
• Physical therapy should be a fundamental component of management for hip or knee osteoarthritis
  • Can be delivered in individual or group format
  • Alternative delivery methods include internet or phone-based therapy 1

Weight Management

• Weight loss is strongly recommended for overweight/obese patients
• Focus on achieving and maintaining weight reduction to improve symptoms and function 1

Supportive Measures

• Assistive devices when appropriate:
  • Canes
  • Walkers
  • Orthotics or joint supports for the knee 1
• Local application of heat or cold for pain management 1

Patient Education

• Explain the nature of osteoarthritis
• Set realistic expectations
• Emphasize importance of self-management 1

Pharmacological Interventions (After Non-Pharmacological Approaches)

First-Line Medications

• Topical treatments:

  • Topical NSAIDs (e.g., diclofenac) for knee osteoarthritis
    • Particularly beneficial in patients >75 years or with gastrointestinal risk factors 1
  • Capsaicin topical for knee osteoarthritis (apply 3-4 times daily) 1

• Oral medications:

  • Acetaminophen (up to 4,000 mg/day) for knee/hand osteoarthritis
  • Acetaminophen or oral NSAIDs for hip osteoarthritis
    • Use oral NSAIDs at lowest effective dose for shortest duration 1

Second-Line Interventions

• Intra-articular corticosteroid injections

  • Provide relief for 4-8 weeks
  • Particularly useful for moderate to severe pain exacerbations 1

• Tramadol

  • Consider for patients who cannot take NSAIDs or have inadequate pain relief 1

Treatment Algorithm

1. Start with non-pharmacological interventions:

   • Structured exercise program
   • Weight loss (if overweight/obese)
   • Physical therapy
   • Assistive devices as needed
   • Patient education

2. If inadequate response, add pharmacological therapy:

   • For knee OA: Begin with topical NSAIDs or capsaicin
   • For hip/hand OA: Begin with acetaminophen
   • If insufficient relief: Consider oral NSAIDs at lowest effective dose

3. For persistent symptoms:

   • Consider intra-articular corticosteroid injections for flares
   • Consider tramadol if NSAIDs contraindicated or ineffective

4. Regular follow-up:

   • Evaluate adherence to exercise program
   • Adjust interventions as needed
   • Monitor for medication adverse effects 1

Special Considerations and Common Pitfalls

Medication Safety

• Acetaminophen: Counsel patients to avoid other products containing acetaminophen to prevent exceeding daily limits
• NSAIDs: Consider higher GI, cardiovascular, and renal risks in elderly patients and those with comorbidities
  • For patients ≥75 years: Prefer topical over oral NSAIDs
  • For patients with GI risk factors: Consider COX-2 selective inhibitor or non-selective NSAID with proton pump inhibitor 1

Treatment Pitfalls to Avoid

• Overreliance on passive treatments instead of active exercise therapy
• Focusing only on pain relief rather than functional improvement
• Discontinuing exercise once symptoms improve (leads to relapse)
• Using supplements without evidence (e.g., chondroitin/glucosamine) 1
• Initiating opioids (including tramadol) as first-line therapy 1
• Prolonged use of oral corticosteroids 1

While older research supports similar approaches 2, 3, 4, the most recent guidelines emphasize the importance of exercise as a cornerstone of treatment 1, 5, 6. The evidence consistently shows that both land-based and water-based exercise programs can improve pain and function in patients with mild to moderate knee and hip OA 6.