What are the treatment options for osteoarthritis (OA)?

Treatment Options for Osteoarthritis

The optimal management of osteoarthritis requires a combination of non-pharmacological and pharmacological approaches, with exercise, education, and weight management forming the cornerstone of treatment, followed by appropriate medication and surgical interventions when necessary. 1

Non-Pharmacological Approaches (First-Line)

Exercise

• Strongly recommended for all patients with knee, hip, and hand OA 1
• Options include:
  • Aerobic exercise (walking, cycling)
  • Strengthening exercises
  • Neuromuscular training
  • Aquatic exercise
• Benefits are greater when exercise is supervised 1
• No specific exercise type is superior; patient preference and accessibility should guide selection

Weight Management

• Essential for overweight/obese patients with OA 1
• Weight loss reduces joint load and improves symptoms
• Should be combined with exercise for optimal outcomes

Education and Self-Management

• Patient education about the nature of OA
• Self-management strategies
• Setting realistic expectations about disease course

Physical Modalities

• Thermal therapy (heat or cold application)
• For hand OA: Orthoses are strongly recommended for first carpometacarpal joint 1
• For knee OA: Bracing is recommended (tibiofemoral braces for tibiofemoral OA; patellofemoral braces for patellofemoral OA) 1

Pharmacological Management

First-Line

• Acetaminophen/Paracetamol (up to 4g/day)
  • Safe option for mild to moderate pain
  • Particularly suitable for elderly patients and those with comorbidities 2

Second-Line

• Topical NSAIDs

  • Recommended for localized pain
  • Lower risk of systemic adverse effects
  • Preferred over oral NSAIDs for patients ≥75 years or with GI risk factors 2

• Oral NSAIDs (when acetaminophen is insufficient)

  • Use minimum effective dose for shortest time possible
  • Consider naproxen or other NSAIDs with proton pump inhibitors for gastric protection 3
  • Caution in elderly patients and those with cardiovascular, renal, or GI risk

Third-Line

• Intra-articular corticosteroid injections

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

• Weak opioids

  • Only when other options have failed
  • Caution due to risk of dependence and side effects 1

Surgical Interventions

• Reserved for patients with advanced disease who have failed conservative management
• Options include:
  • Joint replacement (provides excellent results in appropriate candidates) 1
  • Osteotomy
  • Arthroscopic debridement (limited evidence) 1

Treatment Algorithm

1. Initial Approach:

   • Begin with exercise, weight management (if needed), and education
   • Add acetaminophen for pain relief

2. If inadequate response:

   • Add topical NSAIDs for localized pain
   • Consider oral NSAIDs with gastric protection if necessary

3. For persistent moderate-severe pain:

   • Consider intra-articular corticosteroid injections
   • Consider braces/orthoses for appropriate joints

4. For advanced disease with severe symptoms:

   • Consider surgical evaluation

Important Considerations and Pitfalls

• NSAID risks: Prolonged use increases risk of GI bleeding, cardiovascular events, and renal impairment 2, 3
• Acetaminophen caution: Exceeding recommended limits can cause liver damage
• Exercise adherence: Discontinuing exercise once symptoms improve can lead to relapse
• Supplement caution: Limited evidence supports glucosamine and chondroitin 2
• Active vs. passive treatments: Overreliance on passive treatments instead of active exercise therapy can hinder outcomes 2

The evidence consistently shows that a comprehensive approach combining non-pharmacological interventions (particularly exercise) with appropriate pharmacological management provides the best outcomes for patients with osteoarthritis 1.