What are the management options for osteoarthritis?

Management Options for Osteoarthritis

The management of osteoarthritis should include core treatments of exercise, weight loss (if overweight), and self-management strategies, with pharmacological options and other interventions added as needed for symptom control and to improve quality of life. 1, 2

Core Treatments

Exercise and Physical Activity

• Strongly recommended for all patients with OA 1, 2
• Include both:
  • Local muscle strengthening exercises
  • General aerobic fitness activities
• Exercise programs are more effective when supervised (e.g., by physical therapists) rather than performed alone 1
• Low-impact aerobic exercises show significant pain relief (effect size 0.52) and disability reduction (effect size 0.46) 2

Weight Management

• Strongly recommended for patients with BMI >25 kg/m² 1, 2
• A dose-response relationship exists between weight loss and symptom improvement 1
• Target minimum weight loss of 5-10% of body weight
• Clinical benefits increase with weight loss of 5-10%, 10-20%, and >20% 1
• Weight loss effectiveness is enhanced when combined with exercise 1

Self-Management Programs

• Strongly recommended for all OA patients 1
• Include education about:
  • Disease process
  • Skill-building (goal-setting, problem-solving)
  • Joint protection measures
  • Coping strategies
• Programs typically run 2-6 times weekly 1

Non-Pharmacological Adjunct Treatments

Mind-Body Approaches

• Tai Chi: Strongly recommended for knee and hip OA 1
• Yoga: Conditionally recommended for knee OA 1

Physical Modalities

• Local heat or cold applications 1, 2
• Transcutaneous electrical nerve stimulation (TENS) 1, 2
• Balance exercises (conditionally recommended) 1

Assistive Devices and Supports

• Bracing, joint supports, or insoles for biomechanical joint pain/instability 1, 2
• Walking aids and assistive devices for specific activity limitations 1
• Footwear with shock-absorbing properties 1

Manual Therapy

• Manipulation and stretching (particularly effective for hip OA) 1, 2

Pharmacological Management

First-Line Options

• Acetaminophen/Paracetamol:

  • Initial analgesic for mild to moderate pain (up to 4g/day) 2
  • Regular dosing may be needed 1

• Topical NSAIDs:

  • Recommended for knee and hand OA before oral NSAIDs 1, 2
  • Superior to placebo and equivalent to oral NSAIDs for knee pain with fewer GI adverse events 2

• Topical Capsaicin:

  • Consider for knee OA pain 1, 2
  • Common side effects include local burning/stinging at application site 2

Second-Line Options

• Oral NSAIDs/COX-2 Inhibitors:

  • Use at lowest effective dose for shortest possible time 1, 3
  • Consider individual risk factors (age, comorbidities) 1
  • For osteoarthritis, dosage ranges from 1200-3200 mg daily of ibuprofen 3
  • Prescribe with proton pump inhibitor for GI protection 1
  • Monitor for GI, liver, and cardiorenal toxicity 2

• Opioid Analgesics:

  • Consider if paracetamol or NSAIDs are insufficient 1
  • Not recommended for initial therapy in OA pain 2

• Duloxetine:

  • Consider as alternative or adjunctive therapy when inadequate response to acetaminophen or NSAIDs 2

Interventional Procedures

Intra-articular Injections

• Corticosteroid Injections:
  • Offer for short-term relief of flares or acute symptom deterioration 2
  • Consider for persistent pain inadequately relieved by other interventions 2

Surgical Options

• Joint Replacement:

  • Consider for patients with radiographic evidence of OA, refractory pain and disability despite conservative management 2
  • Generally provides excellent results for advanced disease 4

• Joint-Preserving Procedures:

  • Consider osteotomy in younger adults with symptomatic hip OA 2

Treatment Approach Algorithm

1. Initial Assessment:

   • Evaluate impact on function, quality of life, occupation, mood, relationships, and leisure activities 1
   • Assess pain severity, functional limitations, and comorbidities

2. Start Core Treatments (for all patients):

   • Exercise program (tailored to individual capabilities)
   • Weight loss if overweight/obese
   • Self-management education

3. Add First-Line Pharmacological Treatment (if needed):

   • Acetaminophen for mild pain
   • Topical NSAIDs for knee/hand OA
   • Topical capsaicin as alternative

4. Add Physical Modalities and Assistive Devices (as appropriate):

   • Heat/cold therapy
   • TENS
   • Bracing/supports
   • Walking aids

5. Escalate to Second-Line Pharmacological Treatment (if inadequate response):

   • Oral NSAIDs/COX-2 inhibitors (with PPI if high GI risk)
   • Duloxetine
   • Opioids (limited use)

6. Consider Interventional Procedures (for persistent symptoms):

   • Intra-articular corticosteroid injections
   • Referral for surgical evaluation if severe symptoms persist despite conservative management

7. Regular Monitoring:

   • Reassess after 1-2 weeks of initial treatment
   • Evaluate response after 4-6 weeks
   • Adjust treatment based on response and side effects

Cautions and Pitfalls

1. Medication Safety:

   • NSAIDs carry risks of GI, cardiovascular, and renal adverse effects, especially in older adults 1, 2
   • Use lowest effective dose for shortest duration 3
   • Avoid long-term opioid use due to risk of dependence and side effects 2

2. Treatment Expectations:

   • Inform patients that OA is not inevitably progressive and can be effectively managed 1
   • Set realistic goals for pain reduction and functional improvement
   • Emphasize that treatment response may take time (up to 2 weeks for most interventions) 5

3. Exercise Adherence:

   • Supervised exercise programs show better outcomes than unsupervised ones 1
   • Avoid "peaks and troughs" of activity; consistent moderate activity is better 1

4. Ineffective Treatments:

   • Electroacupuncture is not recommended 1
   • Glucosamine and chondroitin products are not recommended by some guidelines 1, 6
   • Arthroscopic procedures have not shown benefit over sham procedures or optimized therapy 6