What are the management options for an osteoarthritis (OA) flare-up?

Management of Osteoarthritis Flare-ups

The management of osteoarthritis (OA) flare-ups requires a multimodal approach combining physical interventions, topical treatments, and oral analgesics, with topical NSAIDs being the first-line pharmacological treatment due to their favorable safety profile compared to oral medications. 1

Non-Pharmacological Interventions

• Exercise should be continued even during flare-ups, though potentially modified in intensity, as it remains strongly recommended for all OA patients regardless of pain level 1
• Thermal interventions (locally applied heat or cold) are conditionally recommended for symptom relief during flare-ups 1
  • Cold packs may provide symptomatic relief during inflammatory flares 1
  • Heat therapy (such as paraffin for hands) can be beneficial before exercise 2
• Joint protection techniques should be emphasized during flare-ups to minimize stress on affected joints 2
• Self-management strategies should be reinforced to help patients cope with flare symptoms 1, 3
• Assistive devices may be temporarily needed during flares to reduce joint stress 2, 3

Pharmacological Management

Topical Treatments (First-Line)

• Topical NSAIDs are recommended as first-line pharmacological treatment for OA flares, especially for hand OA and in patients ≥75 years old 1, 2
• Topical NSAIDs show similar pain relief as oral NSAIDs with better safety profile 1
• Topical diclofenac gel has demonstrated improvements in pain and function 1
• Topical capsaicin may be considered as an alternative, though it commonly causes burning and stinging sensations 1, 2

Oral Analgesics

• Acetaminophen (paracetamol) at full doses up to 4,000 mg/day can be used for mild to moderate pain during flares 1, 4
• Oral NSAIDs should be considered for limited duration when topical treatments are insufficient 1
  • For OA flares, ibuprofen at doses of 1,200-3,200 mg daily is effective, with the FDA label specifically mentioning use for "osteoarthritis, including flare-ups of chronic disease" 5
  • The lowest effective dose should be used for the shortest duration to minimize adverse effects 5
  • In elderly patients or those with comorbidities, caution is needed due to gastrointestinal, cardiovascular, and renal risks 1

Special Considerations for Different OA Locations

Hand OA Flares

• Orthoses/splints are strongly recommended for thumb base OA flares 2
• Custom-made orthoses are preferred over pre-fabricated ones for better compliance 1
• Paraffin wax therapy is conditionally recommended for hand OA 1, 2

Knee and Hip OA Flares

• Walking aids (such as a cane) may be temporarily needed during flares 3
• Knee sleeves or braces may provide stability and pain relief during flares 3
• Tai Chi is strongly recommended and may help manage both physical symptoms and psychological aspects of flares 3

Managing Psychological Aspects of Flares

• OA flares often impact mood, sleep, and coping abilities 1
• Cognitive-behavioral therapy may be beneficial for patients experiencing significant distress during flares 3
• Addressing sleep disturbances is important as they often worsen during flares 1

Common Pitfalls and Caveats

• Intra-articular corticosteroid injections are not recommended as first-line treatment for flares but may be considered when other approaches fail 1, 2
• Long-term use of oral NSAIDs should be avoided due to potential adverse effects 1
• Opioid analgesics are conditionally recommended against in the initial management of OA flares 2
• Disease-modifying antirheumatic drugs should not be used for OA flares 2
• While prednisone is sometimes used clinically for severe inflammatory flares, it is not specifically recommended in OA guidelines and carries significant risks with prolonged use 6