What are the initial treatment recommendations for osteoarthritis?

Initial Treatment Recommendations for Osteoarthritis

Treatment for osteoarthritis should begin with non-pharmacological approaches including exercise, weight management, and education, followed by topical NSAIDs and acetaminophen as first-line pharmacological options. 1

Non-Pharmacological Interventions (First-Line)

Exercise

• Strongly recommended for all osteoarthritis patients
• Types of recommended exercise:
  • Low-impact aerobic exercise
  • Strengthening exercises
  • Aquatic exercises
  • Neuromuscular training
• Provides significant benefits:
  • Pain relief (effect size: 0.52; 95% CI, 0.34,0.70)
  • Disability reduction (effect size: 0.46; 95% CI, 0.25,0.67) 1

Weight Management

• Strongly recommended for patients with BMI >25
• Target: minimum 5-10% body weight reduction
• Provides clinically important functional improvement (WOMAC function subscale: 0.69; 95% CI, 0.24,1.14) 1

Physical/Occupational Therapy

• Recommended for:
  • Proper exercise instruction
  • Self-efficacy training
  • Thermal therapies (heat/cold applications) 1

Orthotics

• Includes orthopedic shoes, hand splints, and knee orthoses
• Provides small but consistent positive effects 1

Education and Self-Management

• Should include:
  • Information about osteoarthritis
  • Coping strategies for pain
  • Activity maintenance and dosing 1

Pharmacological Interventions

First-Line Medications

• Topical NSAIDs

  • Preferred first-line pharmacological treatment
  • Lower systemic absorption reduces risk of adverse effects 1

• Acetaminophen

  • Alternative first-line option
  • Maximum 3000-4000 mg/day
  • Monitor for hepatic effects with long-term use 1

Second-Line Medications

• Oral NSAIDs (including naproxen)

  • Consider only after failure of first-line treatments
  • Use lowest effective dose
  • Caution in elderly patients and those with cardiovascular, GI, or renal risks
  • Naproxen has been shown to cause less gastric bleeding and erosion than aspirin (1000 mg naproxen vs 3250 mg aspirin) 1, 2

• Intra-articular Corticosteroid Injections

  • For short-term relief during disease flares
  • Not recommended for long-term management 1

Treatment Monitoring and Assessment

• Reassess after 1-2 weeks of initial treatment
• Evaluate response to treatment after 4-6 weeks
• If significant pain persists after non-pharmacological approaches:
  1. Add topical NSAIDs or acetaminophen
  2. Progress to oral NSAIDs if necessary 1

Common Pitfalls to Avoid

• Relying solely on medications: Many providers jump straight to pharmacological management without adequate emphasis on exercise and weight management 1

• Inappropriate use of supplements: Glucosamine and chondroitin are not recommended due to lack of proven efficacy 1

• Ignoring comorbidities: Failing to consider cardiovascular, gastrointestinal, and renal risks when selecting pharmacological treatments, especially in elderly patients 1

• Inadequate exercise instruction: Physical therapy referral is often essential for proper exercise initiation and maintenance 1

• Using unproven treatments: Stem cell injections and tumor necrosis factor inhibitors are not recommended due to insufficient evidence of efficacy and potential risks 1