What are the treatment options for osteoarthritis?

Osteoarthritis Treatment Options

The treatment of osteoarthritis should follow a comprehensive approach that begins with non-pharmacological interventions (exercise and weight loss) as first-line treatment, progressing to pharmacological options (acetaminophen, topical and oral NSAIDs) for symptom management, and considering surgical interventions only when conservative measures fail to provide adequate pain relief and functional improvement. 1

Non-Pharmacological Interventions

Exercise Therapy (First-Line)

• Strongly recommended with high-quality evidence 1
• Types of exercise:
  • Strengthening exercises: Target major muscle groups 2 days/week at moderate to vigorous intensity (60-80% of one repetition maximum) for 8-12 repetitions
  • Aerobic exercise: At least 30 minutes daily of moderate-intensity activity
  • Aquatic exercises: Particularly beneficial for deconditioned patients or those with difficulty performing weight-bearing exercises
  • Neuromuscular training: Balance, agility, and coordination exercises

Weight Management

• Strongly recommended for overweight patients (BMI >28 kg/m²) 1
• Implementation strategies:
  • Set explicit weight-loss goals
  • Provide structured meal plans with balanced combinations of low-calorie foods
  • Start with breakfast
  • Reduce fat intake, especially saturated fats
  • Increase fruit and vegetable intake

Lifestyle Modifications

• Avoid high-impact activities that rapidly load joints 1
• Use appropriate footwear with shock-absorbing properties
• Consider walking aids (used on the contralateral side)
• Raise chair and toilet seat heights to reduce hip pain
• Apply local heat and cold for symptomatic relief

Pharmacological Management

First-Line Pharmacological Therapy

• Acetaminophen (up to 3-4g/day) for mild to moderate pain 1
  • Better safety profile than NSAIDs, especially in elderly patients
  • May be less effective than NSAIDs for moderate-severe pain

Second-Line Pharmacological Options

• Topical analgesics 1

  • Topical NSAIDs, capsaicin cream, or menthol
  • Particularly useful for knee OA with mild to moderate pain
  • Fewer systemic side effects than oral NSAIDs

• Oral NSAIDs 1, 2

  • More effective than acetaminophen for moderate-severe pain
  • Should be used at the lowest effective dose for the shortest duration
  • Consider cardiovascular, gastrointestinal, and renal risk factors
  • Naproxen has been shown to be effective in controlling disease activity with fewer gastrointestinal adverse effects than aspirin or indomethacin 2
  • In studies comparing standard formulations of naproxen, higher doses (1500 mg/day) resulted in more gastrointestinal adverse events than lower doses (750 mg/day) 2

Intra-articular Therapy

• Corticosteroid injections 1

  • Consider for acute pain flares
  • Provides short-term pain relief

• Hyaluronic acid preparations 1

  • Consider when pain is not adequately relieved by other therapies

Last-Line Pharmacological Option

• Opioid analgesics 1
  • Reserved for severe OA pain refractory to other treatments
  • May be preferable to NSAIDs in patients at high risk for NSAID-related adverse events

Surgical Interventions

• Consider when conservative measures fail to provide adequate pain relief and function 1

• Total joint replacement 1

  • Strongly recommended for end-stage disease not responding to conservative measures
  • High strength of evidence

• Joint-preserving procedures 1

  • Osteotomy for younger adults with symptomatic OA
  • Particularly beneficial with dysplasia or varus/valgus deformity

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, 2
• Adjust treatment as needed based on response and side effects

Common Pitfalls and Caveats

1. Overreliance on medications: Many patients and providers focus solely on pain medications while neglecting the critical role of exercise and weight management 1, 3

2. Inadequate exercise prescription: Simply telling patients to "exercise more" without specific guidance often leads to poor adherence. Provide structured exercise programs with clear parameters 1

3. Inappropriate NSAID use: Long-term use of high-dose NSAIDs increases risk of serious gastrointestinal, cardiovascular, and renal adverse events, especially in elderly patients 1, 2

4. Premature surgical referral: Surgery should be considered only after a thorough trial of conservative measures 1

5. Neglecting psychological aspects: Pain catastrophizing and depression can worsen OA symptoms and should be addressed as part of comprehensive management 1