What are the treatment options for osteoarthritis?

Osteoarthritis: Epidemiology, Diagnosis, and Treatment

The optimal management of osteoarthritis requires a comprehensive approach including non-pharmacological interventions (exercise, weight loss) as first-line treatments, followed by pharmacological options (NSAIDs, intra-articular injections) when necessary, with joint replacement surgery considered when conservative measures fail to provide adequate pain relief and functional improvement. 1

Epidemiology

• Osteoarthritis affects approximately 60% of men and 70% of women over age 65 2
• In the United States, approximately 240 per 100,000 persons per year have knee osteoarthritis, with approximately 9.9 million adults having symptomatic knee osteoarthritis as of 2010 3
• Risk factors include genetics, female sex, advancing age, obesity, occupation (jobs requiring repeated knee bending or heavy lifting), and previous joint trauma 3, 2

Core Treatments (First-Line)

Exercise Therapy

• Regular, ongoing exercise program is strongly recommended for all patients with osteoarthritis 3, 1
• Both strengthening exercises and low-impact aerobic activities are beneficial for improving pain and function 3, 4
• Exercise effectiveness is enhanced when patient preferences are considered and when programs are supervised 3, 4
• Aquatic exercises may be particularly helpful for patients who have difficulty with weight-bearing activities 4

Weight Management

• Weight loss interventions are strongly recommended for overweight or obese patients to reduce mechanical stress on weight-bearing joints 3, 1
• Even modest weight loss can significantly improve symptoms and function 5

Patient Education and Self-Management

• Self-management programs are essential to enhance understanding and counter misconceptions about osteoarthritis 3, 1
• Education should emphasize that osteoarthritis is not inevitably progressive and can be effectively managed 3
• Self-efficacy and behavioral change strategies should target positive behaviors such as exercise, weight loss, and activity pacing 3

Non-Pharmacological Adjunct Treatments

Physical Modalities

• Local heat or cold applications for temporary pain relief 3, 1
• Transcutaneous electrical nerve stimulation (TENS) may provide short-term pain relief 3, 2
• Manual therapy, including manipulation and stretching, particularly for hip osteoarthritis 3

Assistive Devices and Supports

• Canes and walking aids to reduce joint load 1
• Braces and joint supports for biomechanical joint pain or instability 3, 1
• First CMC joint orthoses for hand osteoarthritis 3
• Appropriate footwear with shock-absorbing properties 3

Pharmacological Treatment Algorithm

First-Line Medication

• Acetaminophen (paracetamol) for initial pain management at regular dosing up to 4,000 mg/day, with monitoring for potential hepatotoxicity 3, 6
• Topical NSAIDs are recommended before oral NSAIDs, particularly for knee and hand osteoarthritis 3, 1

Second-Line Medication

• Oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period when acetaminophen and topical NSAIDs are insufficient 3, 7
• When prescribing oral NSAIDs/COX-2 inhibitors, add a proton pump inhibitor for gastroprotection 3, 7
• Naproxen has been shown to be effective in controlling disease activity in osteoarthritis, with fewer gastrointestinal side effects than aspirin 7

Third-Line Medication

• Intra-articular corticosteroid injections for moderate to severe pain, particularly with joint effusion 8, 6
• Duloxetine may be considered for patients with inadequate response to other treatments 3, 6
• Tramadol for patients with contraindications to NSAIDs or inadequate response to other treatments 3, 6
• Topical capsaicin may be considered for knee osteoarthritis 3, 6

Important Considerations and Monitoring

Risk Assessment for NSAID Use

• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing NSAIDs, especially in elderly patients 3, 7
• NSAIDs can cause ulcers and bleeding in the stomach and intestines at any time during treatment, which may occur without warning symptoms 7
• The risk of gastrointestinal complications increases with:
  • Concomitant use of corticosteroids or anticoagulants
  • Longer duration of use
  • Smoking
  • Alcohol consumption
  • Older age
  • Poor general health 7

Treatments Not Recommended

• Glucosamine and chondroitin products are not recommended based on current evidence 3
• Acupuncture is not recommended by some guidelines 3 but conditionally recommended by others 3
• Electroacupuncture should not be used 3

Surgical Considerations

• Total joint replacement of the hip, knee, or shoulder is recommended for patients with chronic pain and disability despite maximal medical therapy 9
• Surgery should be considered only after the patient has been offered at least the core treatment options 1

Monitoring and Follow-up

• Regular monitoring of treatment effectiveness is essential as disease course and patient needs change over time 3, 1
• Periodic review should be tailored to individual needs 3