What are the management options for osteoarthritis?

Management Options for Osteoarthritis

Exercise therapy and weight loss are the cornerstone treatments for osteoarthritis management, with pharmacological options serving as adjuncts based on symptom severity and joint involvement. 1, 2

Core Treatments (First-Line)

• Exercise is strongly recommended for all patients with hand, hip, and knee OA, including walking, strengthening exercises, neuromuscular training, and aquatic exercise 1, 2
• Supervised exercise programs are more effective than unsupervised home-based programs 1
• Weight loss is strongly recommended for overweight or obese patients with knee and/or hip OA, with greater benefits observed with weight loss of 5-10%, 10-20%, and >20% 1, 2
• Self-efficacy and self-management programs are strongly recommended to enhance understanding of the condition and develop coping strategies 1, 2

Non-Pharmacological Adjunct Treatments

Joint-Specific Interventions

• For hand OA: First carpometacarpal (CMC) joint orthoses are strongly recommended, while orthoses for other hand joints are conditionally recommended 1, 2
• For knee OA: Tibiofemoral bracing for tibiofemoral OA is strongly recommended; patellofemoral bracing for patellofemoral OA is conditionally recommended 1, 2
• For hip OA: Cane use is strongly recommended to improve mobility and reduce joint load 2

Physical Modalities

• Local heat or cold applications can provide symptomatic relief 1
• Manipulation and stretching are particularly beneficial for hip OA 1
• Transcutaneous electrical nerve stimulation (TENS) can be used for pain relief 1
• Balance exercises are conditionally recommended for knee and hip OA 1

Mind-Body Approaches

• Tai chi is strongly recommended for patients with knee and/or hip OA 1
• Yoga is conditionally recommended for knee OA 1

Pharmacological Management

Topical Treatments

• Topical NSAIDs are strongly recommended for knee OA as first-line pharmacological treatment 1, 2
• Topical capsaicin can be considered for hand and knee OA 1

Oral Medications

• 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 possible period 1, 3
• When prescribing oral NSAIDs, consider patient risk factors (cardiovascular, gastrointestinal, renal) and use with a proton pump inhibitor in high-risk patients 1, 3
• Acetaminophen (paracetamol) can be tried but may have limited efficacy 1, 4
• Duloxetine is conditionally recommended for patients with inadequate response to first-line treatments 2
• Tramadol is conditionally recommended when other options have failed, but carries risks of dependence and side effects 2

Intra-articular Treatments

• Corticosteroid injections are recommended for short-term pain relief during flares 2

Treatments Not Recommended

• Electroacupuncture should not be used 1
• Glucosamine and chondroitin products are not recommended by most guidelines 1, 4

Treatment Algorithm

1. Start with core treatments for all patients: exercise, weight loss (if overweight), and self-management education 1, 2
2. Add physical modalities based on joint involvement: appropriate bracing, orthoses, assistive devices 1, 2
3. Add topical therapies for accessible joints, especially knees, using topical NSAIDs 1, 2
4. Progress to oral medications if inadequate response, starting with oral NSAIDs at the lowest effective dose 1, 3
5. Consider acetaminophen or duloxetine if NSAIDs are contraindicated 1, 2
6. Reserve tramadol for refractory cases 2
7. Consider intra-articular injections for persistent symptoms or flares 2

Important Considerations and Pitfalls

• NSAIDs can cause serious gastrointestinal, cardiovascular, and renal adverse effects, particularly in elderly patients and those with comorbidities 3
• Regular monitoring of treatment effectiveness is essential as disease course and patient needs change over time 1, 4
• Exercise should be continued even when patients experience pain, as there is no uniformly accepted level of pain at which exercise should be avoided 1
• Surgical interventions should be reserved for severe OA unresponsive to conservative management 5, 6