What are the treatment options for osteoarthritis (OA)?

Treatment Options for Osteoarthritis

The most effective treatment approach for osteoarthritis includes a combination of non-pharmacological interventions (exercise, weight management, and education) as first-line therapy, followed by pharmacological options when necessary, with surgery reserved for advanced cases. 1

Affected Joints and Clinical Presentation

Osteoarthritis commonly affects:

• Knee joints
• Hip joints
• Hand joints (particularly first carpometacarpal)
• Spine

Non-Pharmacological Interventions (First-Line)

1. Exercise Therapy

• Low-impact aerobic exercise is strongly recommended for all OA patients, particularly for knee OA 2, 1

  • Walking, cycling, swimming
  • Effect size for pain relief: 0.52 (95% CI, 0.34,0.70) 2
  • Effect size for disability reduction: 0.46 (95% CI, 0.25,0.67) 2

• Strengthening exercises, especially quadriceps strengthening for knee OA 2, 1

  • Resistance training with elastic bands or weight machines
  • Provides statistically significant and possibly clinically important effects on pain and function 2

• Aquatic exercises combine aerobic fitness and joint range of motion in a low-impact environment 2, 1

• Neuromuscular training addresses muscle weakness and reduced sensorimotor control 2, 1

2. Weight Management

• Weight loss is strongly recommended for overweight patients (BMI >25) 2, 1
• Target: Minimum 5-10% of body weight 2, 1
• Provides clinically important functional improvement measured by WOMAC function subscale (0.69; 95% CI, 0.24,1.14) 2
• Implement through dietary modification and appropriate exercise program 2

3. Education and Self-Management

• Provide information about:
  • Nature of osteoarthritis
  • Coping strategies for pain
  • Activity pacing and maintenance 1

4. Assistive Devices

• Orthoses for joint support and stability 1
  • Tibiofemoral braces for knee OA
  • Neoprene or rigid orthoses for hand OA
• Walking aids (canes, walkers) to reduce load on affected joints 1

Pharmacological Interventions (Second-Line)

1. First-Line Medications

• Acetaminophen/Paracetamol (up to 4g/day) 1, 3

  • Safe initial approach for mild to moderate pain
  • Less effective than NSAIDs for moderate-severe pain 4

• Topical NSAIDs 1

  • Good safety profile
  • Localized effect

2. Second-Line Medications

• Oral NSAIDs (e.g., naproxen) 1, 5

  • More effective for moderate-severe pain 4
  • Naproxen has been shown to be effective in controlling disease activity in OA 5
  • Caution: Higher risk of GI adverse events compared to acetaminophen 5
  • In clinical trials, naproxen showed fewer GI adverse effects (nausea, dyspepsia, heartburn) than aspirin or indomethacin 5

• Tramadol for patients who cannot take NSAIDs or have insufficient pain relief 1

3. Intra-articular Therapies

• Corticosteroid injections for short-term relief during disease flares 1, 3
• Hyaluronic acid-like products for pain relief 3

Treatment Algorithm

1. Initial Assessment:

   • Evaluate pain intensity, functional limitations, and affected joints
   • Assess BMI and overall health status

2. First-Line Approach (implement all concurrently):

   • Prescribe appropriate exercise program (aerobic + strengthening)
   • Implement weight management if BMI >25
   • Provide education and self-management strategies
   • Consider assistive devices as needed

3. If inadequate response after 4-6 weeks:

   • Add acetaminophen (up to 4g/day) or topical NSAIDs

4. If still inadequate response:

   • Consider oral NSAIDs (e.g., naproxen)
   • Monitor for adverse effects, especially in elderly patients

5. For acute flares or persistent pain:

   • Consider intra-articular corticosteroid injections

6. For advanced disease with severe symptoms:

   • Consider surgical options (joint replacement)

Common Pitfalls and Caveats

• Overtreatment: Avoid aggressive pharmacological treatment for mild symptoms 6
• Reliance on imaging: Base management on pain severity and functional limitations, not radiographic changes 6
• Inadequate exercise instruction: Physical and occupational therapy referral is often essential for proper exercise initiation and maintenance 2
• Poor adherence: Regular follow-up improves compliance with exercise and weight management programs 7
• Inappropriate expectations: Effect sizes for most non-surgical interventions are small to moderate, but still clinically relevant 6
• Neglecting psychological factors: Pain perception and disability are influenced by psychosocial factors 6

By implementing this comprehensive approach, most patients with OA can achieve significant pain relief and functional improvement, enhancing their quality of life and potentially slowing disease progression.