What is the best treatment for osteoarthritis?

Best Treatment for Osteoarthritis

The optimal management of osteoarthritis requires a combination of exercise, weight management, and appropriate pharmacological interventions, with total joint replacement reserved for end-stage disease. 1

First-Line Treatments

Non-Pharmacological Interventions (Core Treatments)

1. Exercise (High strength of evidence)

   • Aerobic exercise: Low-impact activities, 30 minutes per day, 3-5 times weekly at moderate intensity 1
   • Resistance training: 2-3 times weekly, 8-12 repetitions at 60-80% of maximum 1
   • Aquatic exercises: Particularly beneficial for deconditioned patients 1

2. Weight Management (High strength of evidence)

   • Strongly recommended for patients with BMI >28 kg/m² 1
   • Structured meal plans with explicit weight-loss goals 1

3. Physical Modalities

   • Local heat and cold applications 1
   • Appropriate footwear with shock-absorbing properties 1
   • Assistive devices (walking sticks used on contralateral side) 1

Pharmacological Interventions

1. First-line medication

   • Acetaminophen/Paracetamol (Moderate strength of evidence)
     • Maximum recommended dosage: 3g daily 1
     • Monitor for hepatotoxicity 1
     • Preferred for long-term oral analgesia 2

2. Second-line medications

   • NSAIDs (Moderate strength of evidence)
     • Oral NSAIDs (e.g., naproxen): For patients with inflammation and stiffness 1, 3
     • Topical NSAIDs (e.g., diclofenac): For knee osteoarthritis 1, 4
     • Consider GI risk factors when prescribing 1

Second-Line and Advanced Treatments

1. Intra-articular Injections

   • Corticosteroid injections: For acute exacerbations, especially with effusion 2, 1
     • Provides 1-3 months of pain relief 1
   • Hyaluronic acid injections: For patients with contraindications to NSAIDs 1

2. Adjunctive Pharmacotherapy

   • Duloxetine: For severe or refractory pain, starting at 30mg/day 1
   • Tramadol: When other options fail 1
   • Opioids: Reserved for severe pain refractory to other treatments 1

3. Surgical Interventions

   • Total joint replacement: Strongly recommended for end-stage disease not responding to conservative measures 1
   • Joint-preserving procedures (e.g., osteotomy): For younger adults with symptomatic OA 1

Treatment Algorithm

1. Initial Management:

   • Begin with exercise program + weight management if overweight
   • Add acetaminophen for pain control (up to 3g daily)

2. If inadequate response after 2-4 weeks:

   • Add topical NSAIDs for knee OA or
   • Switch to oral NSAIDs if inflammation is present
   • Continue exercise and weight management

3. If still inadequate response:

   • Consider intra-articular corticosteroid injection for acute flares
   • Add adjunctive therapy (duloxetine or tramadol)

4. For persistent severe symptoms:

   • Consider referral for surgical evaluation
   • Total joint replacement for end-stage disease

Important Considerations

• Regular assessment of pain control and functional status is necessary to monitor treatment efficacy 1
• NSAIDs have increased risk of gastrointestinal adverse events compared to acetaminophen 1
• Exercise should be considered regardless of age, structural disease severity, functional status, or pain levels 5
• The disease course and patient's requirements often change over time, requiring periodic review and adjustment of therapy 6

Common Pitfalls to Avoid

• Relying solely on pharmacological treatments without implementing core non-pharmacological interventions
• Prolonged use of NSAIDs without gastroprotection in high-risk patients
• Delaying appropriate exercise therapy due to pain concerns
• Overlooking weight management as a critical component of treatment
• Using opioids as early-line therapy rather than as a last resort

Remember that while medications provide symptomatic relief, exercise and weight management can actually modify disease progression and improve long-term outcomes.