What medications cover osteoarthritis treatment?

Medications for Osteoarthritis Treatment

Paracetamol (acetaminophen) and NSAIDs are the primary pharmacological treatments for osteoarthritis, with topical NSAIDs recommended as first-line therapy for knee and hand osteoarthritis before oral NSAIDs, COX-2 inhibitors, or opioids. 1

First-Line Medications

Non-Pharmacological Core Treatments (Always Recommended)

• Exercise (strengthening and aerobic fitness)
• Weight loss if overweight or obese
• Patient education about the condition

First-Line Pharmacological Options

1. Paracetamol (Acetaminophen)

   • Dosage: Up to 4g/day with regular dosing
   • Benefits: Statistically significant pain relief compared to placebo 1
   • Safety: Lower risk of GI complications compared to NSAIDs 1
   • Best for: Mild to moderate pain, especially in elderly patients

2. Topical NSAIDs

   • Examples: Diclofenac gel
   • Benefits: Statistically significant effects on pain, stiffness, and function 1
   • Safety: Lower systemic absorption, fewer GI side effects 2
   • Best for: Knee and hand osteoarthritis 1

Second-Line Medications

1. Oral NSAIDs

   • Types:
     • Non-selective NSAIDs (e.g., ibuprofen, naproxen)
     • COX-2 selective inhibitors
   • Dosing: Lowest effective dose for shortest possible period 1
   • Benefits: More effective than acetaminophen for pain relief 1
   • Safety concerns: GI, cardiovascular, and renal risks 3
   • Risk reduction: Add proton pump inhibitor when using oral NSAIDs 1

2. Topical Capsaicin

   • Application: 3-4 times daily
   • Benefits: Local pain relief 2
   • Best for: Knee osteoarthritis 1

Third-Line Medications

1. Opioid Analgesics

   • Examples: Tramadol
   • When to use: If paracetamol or NSAIDs are insufficient 1
   • Benefits: Additional pain relief
   • Concerns: Risk of dependence, side effects
   • Best practice: Short-term use only

2. Intra-articular Corticosteroid Injections

   • Benefits: Short-term pain relief (4-8 weeks) 1
   • Best for: Moderate to severe pain exacerbations 2
   • Evidence: Clinically important and statistically significant effects on pain at 1-2 weeks 1

Medication Selection Algorithm

1. Start with core non-pharmacological treatments for all patients (exercise, weight loss if needed)

2. For initial pharmacological treatment:

   • For knee/hand OA: Start with paracetamol and/or topical NSAIDs 1
   • For hip OA: Start with paracetamol or oral NSAIDs 2

3. If inadequate response:

   • Add or substitute with oral NSAIDs/COX-2 inhibitors + PPI 1
   • Consider patient-specific factors:
     • Age ≥75: Prefer topical NSAIDs over oral 2
     • GI risk factors: Use COX-2 inhibitor or non-selective NSAID with PPI 2
     • Cardiovascular risk: Avoid high-dose NSAIDs, especially diclofenac 1

4. For breakthrough pain or flares:

   • Consider intra-articular corticosteroid injections 1

5. For refractory pain:

   • Consider opioid analgesics (tramadol) 1, 2
   • Consider referral for surgical evaluation if severe functional limitation persists 1

Common Pitfalls to Avoid

• Overreliance on medications: Core treatments (exercise, weight management) should always be maintained 1

• Prolonged NSAID use: Increases risk of GI bleeding, cardiovascular events, and renal impairment 3

• Exceeding paracetamol limits: Maximum 4g daily, with caution to avoid other products containing acetaminophen 2

• Using glucosamine/chondroitin: Not recommended by guidelines due to insufficient evidence 1, 2

• Starting with opioids: Should be reserved for when other options have failed 2

• Neglecting topical options: Topical NSAIDs have similar efficacy with fewer systemic side effects for knee and hand OA 1, 4

By following this evidence-based medication approach while maintaining core non-pharmacological treatments, most patients with osteoarthritis can achieve meaningful pain relief and functional improvement.