Treatment Options for Osteoarthritis
The optimal management of osteoarthritis requires a comprehensive approach combining non-pharmacological core treatments (exercise, weight loss, and self-management education) with targeted pharmacological interventions and physical modalities based on joint involvement and symptom severity. 1, 2
Core Treatments (First-Line)
- Regular exercise programs should be implemented for all patients with osteoarthritis, including walking, strengthening exercises, and aquatic exercise to improve pain and function 1, 2
- Weight loss is strongly recommended for overweight or obese patients with knee and/or hip OA to reduce joint load and improve symptoms 1, 2
- Self-efficacy and self-management programs should be provided to all patients to enhance understanding of the condition and develop coping strategies 1, 2
Non-Pharmacological Interventions
Joint-Specific Approaches
- Hand OA: First carpometacarpal (CMC) joint orthoses are strongly recommended; orthoses for other hand joints and kinesiotaping are conditionally recommended 1, 2
- Knee OA: Tibiofemoral bracing for tibiofemoral OA (strong recommendation); patellofemoral bracing for patellofemoral OA (conditional recommendation) 1, 2
- Hip OA: Cane use is strongly recommended to improve mobility and reduce load on affected joints 1, 3
Additional Physical Modalities
- Local heat or cold applications for symptomatic relief 2
- Manipulation and stretching, particularly beneficial for hip OA 2
- Transcutaneous electrical nerve stimulation (TENS) for pain relief 2
- Balance exercises and yoga are conditionally recommended 2, 1
Pharmacological Management
First-Line Medications
- Topical NSAIDs are strongly recommended for knee OA as they provide effective pain relief with minimal systemic exposure 1, 2
- Oral NSAIDs (including COX-2 inhibitors) are strongly recommended for hand, knee, and hip OA, but should be used at the lowest effective dose for the shortest duration due to gastrointestinal and cardiovascular risks 1, 4
Second-Line Medications
- Acetaminophen (paracetamol) is conditionally recommended for mild to moderate pain, though recent guidelines have downgraded its importance due to limited efficacy 1, 3, 5
- Duloxetine is conditionally recommended for patients with inadequate response to first-line treatments or with comorbid depression 1, 2
- Tramadol is conditionally recommended when other options have failed, but carries risks of dependence and side effects 1, 3
Intra-articular Therapies
- Corticosteroid injections are strongly recommended for knee and hip OA for short-term pain relief during flares 1, 2
- Hyaluronic acid injections have mixed evidence and are not universally recommended 3, 5
Treatments Not Recommended
- Electroacupuncture 2
- Glucosamine and chondroitin products (not recommended by most guidelines despite popular use) 2, 3
Treatment Algorithm
- Start with core treatments for all patients: exercise, weight loss (if applicable), and self-management education 1, 2
- Add physical modalities based on joint involvement: appropriate bracing, orthoses, assistive devices 1, 2
- Add topical therapies for accessible joints (especially knees): topical NSAIDs 1, 2
- Progress to oral medications if inadequate response:
- Consider intra-articular injections for persistent symptoms or flares 1, 2
Important Considerations and Pitfalls
- NSAID safety concerns: Patients with cardiovascular disease, renal impairment, or history of gastrointestinal bleeding require careful monitoring when using NSAIDs 4
- Avoid over-reliance on medications: Non-pharmacological approaches should remain the foundation of treatment throughout the disease course 2
- Regular monitoring: Treatment plans should be periodically reviewed and adjusted as the disease progresses 2, 6
- Recognize limitations: Current treatments focus on symptom management rather than disease modification; no treatments have definitively shown to reverse cartilage damage 6, 7