What are the treatment options for osteoarthritis?

Treatment Options for Osteoarthritis

Exercise therapy, weight loss for overweight individuals, and education should form the foundation of osteoarthritis treatment, with pharmacological options added when non-pharmacological approaches provide insufficient relief. 1

Non-Pharmacological Interventions (First-Line)

Exercise Therapy

• Supervised exercise programs are strongly recommended and should include:
  • Low-impact aerobic exercises (walking, swimming)
  • Muscle strengthening (especially quadriceps for knee OA)
  • Aquatic exercises
  • Neuromuscular training 1
• Exercise is more effective when supervised and should be tailored to the specific joint affected 2

Weight Management

• Weight loss of 5-10% can provide significant symptom relief in patients with BMI ≥25 kg/m² 1
• This reduces joint stress and mechanical load, particularly beneficial for knee and hip OA 1

Patient Education and Self-Management

• Education about the nature of osteoarthritis
• Coping strategies for pain
• Maintenance and appropriate dosing of activities 1

Supportive Devices

• Walking aids (canes, walkers) to reduce load on affected joints
• Appropriate footwear for knee and hip OA
• Orthoses (braces) for tibiofemoral OA and hand OA 1

Pharmacological Interventions

First-Line Medications

• Acetaminophen/Paracetamol (up to 4g/day)
  • Safest initial approach for mild to moderate pain 1, 3
• Topical NSAIDs
  • Effective for knee and hand OA with fewer systemic side effects 1

Second-Line Medications

• Oral NSAIDs (including naproxen)
  • More effective than acetaminophen for moderate-severe pain 1, 4
  • Should be used at the lowest effective dose for the shortest duration 4
  • Caution: Increased risk of GI bleeding, cardiovascular events, and renal impairment 4
  • In clinical trials, naproxen has shown effectiveness in controlling OA symptoms with fewer GI and nervous system adverse effects than aspirin or indomethacin 4

Intra-articular Injections

• Corticosteroid injections
  • Provide short-term relief (4-8 weeks) during acute flares 1, 5
• Hyaluronic acid injections
  • More expensive but may maintain symptom improvement for longer periods 5

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Supervised exercise program
   • Weight loss if overweight/obese
   • Patient education
   • Supportive devices as needed

2. If pain persists after 4-6 weeks, add pharmacological treatment:

   • Begin with acetaminophen (up to 4g/day) or topical NSAIDs
   • If insufficient relief, progress to oral NSAIDs (like naproxen) at the lowest effective dose
   • Consider intra-articular corticosteroid injections for acute flares

3. For advanced disease with chronic pain and disability despite maximal therapy:

   • Consider referral for total joint replacement 5

Important Considerations and Precautions

• NSAIDs (including naproxen):

  • Increased risk of GI ulceration and bleeding, especially in older adults, those taking corticosteroids or anticoagulants, smokers, and alcohol users 4
  • Cardiovascular risks including hypertension, heart attack, and stroke 4
  • Regular monitoring of blood pressure and renal function is necessary 1
  • Use the lowest effective dose for the shortest duration possible 4

• Not Recommended:

  • Glucosamine and chondroitin (lack of efficacy) 1
  • Tumor necrosis factor inhibitors and interleukin-1 receptor antagonists 1
  • Stem cell injections (insufficient evidence) 1

• Regular reassessment is essential to evaluate treatment response and adjust therapy as needed 1

The optimal management of osteoarthritis requires a comprehensive approach that combines non-pharmacological and pharmacological interventions, with exercise therapy, weight management, and education forming the cornerstone of treatment. Medications should be added when these measures provide insufficient relief, starting with safer options and progressing as needed while carefully monitoring for adverse effects.