What is the best plan of care for a 65-year-old female with bilateral osteoarthritic (degenerative joint disease) knee pain?

From the Guidelines

The best plan of care for a 65-year-old female with bilateral osteoarthritic knee pain should begin with conservative management, focusing on non-pharmacological and pharmacological treatment modalities tailored to her individual needs, as recommended by the most recent guidelines 1. The management of knee osteoarthritis (OA) requires a comprehensive approach, considering the patient's overall health, lifestyle, and preferences.

• Non-pharmacological treatment modalities, such as regular education, exercise, and weight reduction, are essential components of the management plan.
• Exercise programs, including aerobic, aquatic, and/or resistance exercises, have been shown to improve pain and function in patients with knee OA 1.
• Weight loss, if the patient is overweight, can significantly reduce joint loading and improve symptoms.
• Assistive devices, such as canes or walkers, can help reduce knee loading and improve mobility.
• Pharmacological treatment options, including acetaminophen, NSAIDs, and intra-articular corticosteroid injections, can be used to manage pain and inflammation.
• The American Academy of Orthopaedic Surgeons (AAOS) recommends a stepped-care approach, starting with non-pharmacological treatments and progressing to pharmacological and invasive treatments as needed 1. Key considerations in the management of knee OA include:
• Patient education and self-management
• Regular exercise and physical activity
• Weight management
• Pain management using a stepped-care approach
• Consideration of invasive treatments, such as joint replacement, for patients with severe and refractory symptoms. Overall, the goal of treatment is to improve the patient's quality of life, reduce pain and disability, and slow the progression of the disease.
• The most recent guidelines from the AAOS provide a comprehensive framework for the management of knee OA, emphasizing the importance of a patient-centered approach and the need for ongoing monitoring and adjustment of the treatment plan 1.

From the FDA Drug Label

In patients with osteoarthritis, the therapeutic action of naproxen has been shown by a reduction in joint pain or tenderness, an increase in range of motion in knee joints, increased mobility as demonstrated by a reduction in walking time, and improvement in capacity to perform activities of daily living impaired by the disease

The best plan of care for a 65-year-old female with bilateral osteoarthritic knee pain may include the use of naproxen to reduce joint pain and improve mobility.

• The patient's age does not appear to affect the response to naproxen, as studies have shown that response to naproxen is not dependent on age or sex.
• However, it is essential to monitor the patient's hepatic and renal function during long-term administration of naproxen, especially in geriatric patients.
• The recommended dose of naproxen for osteoarthritis is not explicitly stated in the provided text, but it is mentioned that doses of 375 mg twice daily or 750 mg twice daily were used in clinical trials 2.

From the Research

Best Plan of Care for Bilateral Osteoarthritic Knee Pain

The best plan of care for a 65-year-old female with bilateral osteoarthritic knee pain involves a combination of conservative treatments.

• Weight reduction, if the patient has a BMI > 28kg/m^2, is recommended 3
• Physical therapy and rehabilitation, including aerobic, proprioception, and strengthening training, can help improve function and reduce pain 3, 4
• Self-management education programs can empower patients to better manage their condition 3, 4
• Pharmacological treatment, such as NSAIDs (ibuprofen, diclofenac, aceclofenac), IA corticosteroid, and IA hyaluronic acid, can be used to manage pain and inflammation 3
• Exercise therapy, including hip and knee strengthening exercises, can help improve function and reduce pain 4

Diagnosis and Treatment

A standard musculoskeletal and neurological examination is required for the diagnosis of knee OA 5.

• Medical imaging may be performed to improve specificity, but radiographic imaging of all patients with possible knee OA is not recommended 4
• The differential diagnosis should exclude other causes of knee pain, including bone and joint disorders such as rheumatoid arthritis, spondylo- and other arthropathies, and infections 5
• When conservative treatment fails, intra-articular injections of corticosteroids and radiofrequency (conventional and cooled) of the genicular nerves have been shown to be effective 5
• Hyaluronic acid infiltrations are conditionally recommended, while platelet-rich plasma infiltrations, chemical ablation of genicular nerves, and neurostimulation have limited evidence and can be considered in a study setting 5

Multidisciplinary Approach

A multidisciplinary approach, including psychological therapy, integrative treatments, and procedural options such as intra-articular injections, radiofrequency ablation, and surgery, may be necessary when conservative measures fail to provide satisfactory pain relief 5, 6.

• Surgical referral for knee joint replacement can be considered for patients with end-stage OA after using all appropriate conservative options 4