What are the guidelines for managing osteoarthritis?

Guidelines for Managing Osteoarthritis

The management of osteoarthritis should be patient-centered and focus on core treatments including exercise, education, and weight loss (where appropriate), with pharmacological and surgical interventions reserved for those who don't respond to these core approaches. 1, 2

Core Non-Pharmacological Interventions

Exercise Therapy (Strongly Recommended)

• Land-based exercises: Includes aerobic and resistance training to improve pain and function 1
• Aquatic exercises: Particularly beneficial for patients with bilateral hip osteoarthritis 1
• Tai Chi and Yoga: Strongly recommended for knee and hip osteoarthritis 1
• Balance exercises: Conditionally recommended for all osteoarthritis patients 1

Education and Self-Management

• Provide appropriate information about the condition to counter misconceptions (e.g., that osteoarthritis is inevitably progressive and untreatable) 2
• Include information about disease process, joint protection techniques, and activity modification 1
• Emphasize self-management strategies focusing on core treatments 2

Weight Management

• Target minimum weight loss of 5-10% of body weight for overweight or obese patients 1
• Weight reduction has proven benefit in obese patients with knee osteoarthritis 3

Assistive Devices and Orthoses

• Hand orthoses: Strongly recommended for hand osteoarthritis 1, 2
• Knee orthoses: Sleeves and elastic bandages beneficial for knee osteoarthritis 1
• Walking aids: Consider canes or walkers to reduce pain with weight-bearing 1
• Appropriate footwear: Shoes with shock-absorbing properties 2

Pharmacological Interventions

First-Line Medications

• Acetaminophen/Paracetamol: Initial oral analgesic (up to 3g/day), considering patient's age and comorbidities 1, 4
• Topical NSAIDs: Safe alternative for elderly patients with comorbidities, with lower systemic absorption reducing adverse effects risk 1

Second-Line Medications

• Oral NSAIDs: Use lowest effective dose for shortest duration 1
  • Caution: Monitor for GI side effects including ulcers and bleeding, which can occur without warning symptoms 5
  • Risk factors for NSAID complications: Concurrent corticosteroids or anticoagulants, longer use, smoking, alcohol consumption, older age, poor health 5
  • Contraindications: History of asthma attack, hives, or allergic reaction with aspirin or other NSAIDs; recent heart bypass surgery 5

Intra-articular Treatments

• Corticosteroid injections: May provide short-term relief for persistent pain 1, 4
• Hyaluronic acid-like products: Consider if oral medications provide inadequate pain relief 4

Surgical Interventions

• Total joint replacement: Strongly recommended for end-stage disease not responding to conservative measures 1
• Joint-preserving procedures: Consider osteotomy for younger adults, especially with dysplasia or varus/valgus deformity 1
• Surgical referral criteria: Failed conservative treatment, pain significantly impacting quality of life, confirmed structural abnormalities on imaging 1

Monitoring and Follow-up

• Regular assessment of pain control and functional status to monitor treatment efficacy 1
• Monitor for medication side effects, particularly with NSAIDs 1, 5
• Provide periodic review tailored to individual needs 2

Treatment Algorithm

1. Initial Assessment:

   • Assess impact on function, quality of life, occupation, mood, relationships, and leisure activities 2
   • Consider comorbidities that may compound osteoarthritis effects 2

2. Start Core Treatments (for all patients):

   • Prescribe appropriate exercise program
   • Provide education about the condition
   • Recommend weight loss if overweight/obese

3. If inadequate response, add:

   • Assistive devices/orthoses appropriate to affected joints
   • Local heat or cold applications
   • Acetaminophen/paracetamol (up to 3g/day)

4. If still inadequate response:

   • Consider topical NSAIDs (especially for elderly or those with comorbidities)
   • Consider oral NSAIDs at lowest effective dose with appropriate monitoring
   • Consider intra-articular corticosteroid injections for flares

5. For persistent disabling symptoms despite above measures:

   • Consider surgical referral for joint replacement or preserving procedures

Common Pitfalls to Avoid

• Relying solely on pharmacological management without implementing core non-pharmacological treatments
• Failing to address modifiable risk factors (obesity, muscle weakness, poor biomechanics)
• Long-term opioid use, which has limited evidence of superior efficacy and higher risk of side effects and dependency 1
• Using NSAIDs without appropriate monitoring for adverse effects, especially in high-risk patients 5
• Delaying surgical referral when conservative measures have failed and quality of life is significantly impacted