What are the initial management strategies for osteoarthritis (OA)?

Initial Management Strategies for Osteoarthritis

The initial management of osteoarthritis should focus on a multimodal approach that combines non-pharmacological interventions (exercise, weight loss, and self-management) with appropriate pharmacological options tailored to the patient's specific joint involvement and symptom severity. 1

Non-Pharmacological Core Management

Exercise Therapy

• Land-based exercise (including aerobic, strength, flexibility, or neuromotor training) is strongly recommended as first-line treatment for all patients with knee and hip OA 1
• Aquatic exercise is strongly recommended for patients with hip and knee OA, particularly beneficial for those who have difficulty with weight-bearing activities 1
• Exercise programs are more effective when supervised (often by physical therapists) rather than performed independently at home 1
• The mode of exercise delivery should be selected according to patient preferences and local availability (individual/group sessions, supervised/unsupervised, face-to-face/digital technology) 1
• Balance exercises are conditionally recommended for patients with knee and/or hip OA to improve stability and potentially reduce fall risk 1

Weight Management

• Weight loss is strongly recommended for patients with knee and/or hip OA who are overweight or obese 1
• A dose-response relationship exists between the amount of weight loss and symptom improvement - even 5% weight loss can produce clinically meaningful benefits 1, 2
• The combination of weight loss and exercise programs enhances effectiveness for symptom management 1, 3

Self-Management and Education

• Self-efficacy and self-management programs are strongly recommended for patients with knee, hip, and hand OA 1
• Patient education should focus on the nature of OA, its causes, consequences, prognosis, and activity pacing techniques 1, 4
• Self-management strategies should be introduced early and reinforced at subsequent clinical encounters 1, 5

Assistive Devices and Physical Modalities

• Walking aids (such as canes) are conditionally recommended for patients with hip and knee OA to reduce joint loading 1
• Bracing is strongly recommended for tibiofemoral OA and conditionally recommended for patellofemoral OA 1, 3
• Thermal agents (heat or cold) can provide temporary pain relief and should be incorporated into self-management strategies 1, 6
• Manual therapy in combination with supervised exercise is conditionally recommended for hip OA 1

Pharmacological Management

First-Line Options

• Topical NSAIDs are strongly recommended for knee OA due to their favorable safety profile compared to oral NSAIDs 1, 4, 3
• Acetaminophen (up to 4,000 mg/day) is conditionally recommended as initial pharmacologic therapy due to its favorable safety profile, though it has somewhat lower efficacy than NSAIDs 1, 4, 3

Second-Line Options

• Oral NSAIDs are conditionally recommended when acetaminophen and topical NSAIDs provide insufficient relief 1, 7
• NSAIDs should be used at the lowest effective dose for the shortest duration possible to minimize adverse effects 7, 8
• For patients with GI risk factors requiring oral NSAIDs, use a COX-2 selective inhibitor or combine a nonselective NSAID with a proton-pump inhibitor 3, 8

Additional Options

• Intra-articular corticosteroid injections are conditionally recommended for hip OA and strongly recommended for knee OA, particularly for acute pain relief with effusion 1, 3
• Duloxetine may be considered if other pharmacological treatments are ineffective, starting at 30 mg/day and increasing to 60 mg/day 3, 9
• Tramadol is conditionally recommended for hip OA when other pharmacologic options are insufficient 1

Important Considerations and Pitfalls

• Avoid glucosamine and chondroitin supplements as they are conditionally not recommended based on current evidence 1, 6
• Long-term opioid use should be avoided as evidence does not support their use in OA management 3, 10
• Regular monitoring of treatment effectiveness is essential as disease course and patient needs change over time 6, 5
• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing NSAIDs, especially in elderly patients 6, 7
• No effective disease-modifying agents for OA have yet been identified, so management focuses on symptom control and functional improvement 1, 8
• The comprehensive approach to OA management should be periodically reviewed and adjusted as the patient's condition and needs evolve 8, 5