Is low dose radiation therapy effective for treating osteoarthritis?

Low Dose Radiation Therapy for Osteoarthritis

Low dose radiation therapy is not recommended for the treatment of osteoarthritis due to lack of evidence for efficacy and potential safety concerns. 1

Evidence Against Low Dose Radiation Therapy

• High-quality randomized controlled trials have failed to demonstrate substantial beneficial effects of low-dose radiation therapy (LDRT) for osteoarthritis compared to sham treatment 2, 3, 4
• A randomized, double-blinded, sham-controlled trial found no significant difference in response rates between LDRT and sham treatment for knee osteoarthritis (44% vs 43% respectively) 4
• Similarly, a randomized trial for hand osteoarthritis showed no significant difference in responder rates between LDRT and sham treatment at 3 months (29% vs 36%) 2
• Long-term follow-up at 6 and 12 months also showed no delayed beneficial effects of LDRT for both knee and hand osteoarthritis 3
• Radiation therapy has been associated with increased risk of malignancies, particularly leukemia and cancers at irradiated sites 1

Recommended Approaches for Osteoarthritis Management

Non-Pharmacological Interventions (First-Line)

• Exercise is strongly recommended for knee and hip OA, including walking, strengthening, neuromuscular training, and aquatic exercise 5
• Weight loss is strongly recommended for patients with knee and/or hip OA who are overweight or obese 5
• Self-efficacy and self-management programs are strongly recommended 5
• Tai chi is strongly recommended for knee and hip OA 5
• Canes and other assistive devices are strongly recommended for appropriate patients 5
• Bracing is strongly recommended for tibiofemoral knee OA and conditionally recommended for patellofemoral OA 5
• Hand orthoses are strongly recommended for first carpometacarpal joint OA 5

Pharmacological Interventions

• Topical NSAIDs are strongly recommended for knee OA and conditionally recommended for hand OA 5
• Oral NSAIDs are strongly recommended, with appropriate gastrointestinal protection 5
• Intra-articular glucocorticoid injections are strongly recommended for knee OA and conditionally recommended for hip and hand OA 5
• Acetaminophen is conditionally recommended, particularly as first-line oral analgesic 5
• Duloxetine and tramadol are conditionally recommended for patients with inadequate response to other therapies 5

Treatment Algorithm for Osteoarthritis

1. Core treatments (should be offered to all patients):

   • Education and self-management strategies 5
   • Exercise (supervised when possible) 5
   • Weight loss if overweight/obese 5

2. First-line pharmacological treatment:

   • Topical NSAIDs for knee and hand OA 5
   • Acetaminophen (paracetamol) for regular dosing 5

3. Second-line pharmacological treatment:

   • Oral NSAIDs/COX-2 inhibitors with proton pump inhibitor for GI protection 5
   • Intra-articular corticosteroid injections for moderate to severe pain 5

4. Third-line pharmacological treatment:

   • Duloxetine 5
   • Tramadol (conditionally recommended over non-tramadol opioids) 5

5. Surgical options:

   • Consider joint replacement for refractory pain associated with disability and radiological deterioration 5

Common Pitfalls and Caveats

• Avoid using LDRT based solely on older, uncontrolled studies that reported positive outcomes, as these effects are likely explained by regression to the mean and placebo response 3, 6
• Non-tramadol opioids should be used with extreme caution and only when alternatives have been exhausted due to modest benefits and high risk of toxicity and dependence 5
• Glucosamine, chondroitin, and other supplements (fish oil, vitamin D) are not recommended due to lack of convincing evidence 5
• Arthroscopic lavage and debridement should not be routinely offered unless there is a clear history of mechanical locking 5
• While some older studies suggested benefit from LDRT 7, the methodological quality was inferior to recent randomized controlled trials that found no benefit 2, 3, 4