What are the general recommendations to manage osteoarthritis in adult patients?

Management of Osteoarthritis in Adult Patients

The core management of osteoarthritis should focus on exercise, weight management, and education, with pharmacological treatments used as adjuncts when necessary. 1, 2

Core Non-Pharmacological Treatments

Exercise and Physical Activity

• Strongly recommended for all OA patients 2
  • Low-impact aerobic exercise
  • Muscle strengthening exercises
  • Aquatic exercises
  • Neuromuscular training
• Exercise provides significant pain relief (effect size 0.52) and disability reduction (effect size 0.46) 2
• Physical therapy referral recommended for proper exercise instruction and self-efficacy training 2

Weight Management

• Weight loss strongly recommended for patients with BMI >25 2
• Target minimum 5-10% of body weight loss 2
• Provides clinically important functional improvement 2

Patient Education

• Provide appropriate information about osteoarthritis 1
• Counter misconceptions (e.g., OA is not inevitably progressive) 1
• Teach coping strategies and activity pacing 2
• Self-management strategies emphasizing core treatments 1

Adjunct Non-Pharmacological Treatments

• Local applications:

  • Heat or cold therapy 1
  • TENS (Transcutaneous Electrical Nerve Stimulation) 1

• Biomechanical interventions:

  • Appropriate footwear with shock-absorbing properties 1
  • Bracing, joint supports, or insoles for biomechanical joint pain/instability 1
  • Assistive devices (walking sticks, tap turners) for specific functional limitations 1

• Manual therapy:

  • Manipulation and stretching (particularly effective for hip OA) 1

Pharmacological Management Algorithm

1. First-line:

   • Acetaminophen/paracetamol (regular dosing may be needed) 1, 2
   • For knee and hand OA: Consider topical NSAIDs before oral options 1, 2

2. Second-line (if first-line inadequate):

   • Topical capsaicin 1
   • Add opioid analgesics OR
   • Substitute/add oral NSAIDs or COX-2 inhibitors 1

3. NSAID considerations:

   • Use lowest effective dose for shortest possible time 1, 3
   • First choice: either COX-2 inhibitor (except etoricoxib 60mg) or standard NSAID 1
   • Prescribe with proton pump inhibitor 1
   • For OA patients requiring low-dose aspirin, consider other analgesics first 1
   • For osteoarthritis, ibuprofen dosage: 1200-3200mg daily (400mg, 600mg or 800mg three or four times daily) 3

4. Intra-articular therapy:

   • Corticosteroid injections for moderate to severe pain relief 1, 2

Important Cautions and Considerations

• Avoid or use with caution:

  • Electroacupuncture is not recommended 1
  • Glucosamine and chondroitin products are not recommended 1, 2
  • Stem cell injections are not recommended due to lack of standardization and insufficient evidence 2
  • TNF inhibitors and IL-1 receptor antagonists are strongly discouraged for erosive hand OA 2

• Risk assessment:

  • Consider individual risk factors (including age) when choosing NSAIDs 1
  • Monitor for gastrointestinal, liver, and cardiorenal toxicity with NSAIDs 1
  • Use particular caution with pharmacological treatments in elderly patients 1, 2

Treatment Monitoring

• Provide periodic review tailored to individual needs 1
• Reassess after 1-2 weeks of initial treatment 2
• Evaluate response to treatment after 4-6 weeks 2
• Monitor disease activity using validated measures like WOMAC pain scale 2
• Immediately reevaluate if symptoms worsen 2

Common Pitfalls to Avoid

• Relying solely on pharmacological management without adequate emphasis on exercise and weight management 2
• Failing to consider comorbidities when selecting treatments for elderly patients 2
• Providing inadequate exercise instruction (physical therapy referral often essential) 2
• Using opiates as first-line treatment (should be avoided when possible) 2, 4