What are the treatment options for osteoarthritis?

Treatment Options for Osteoarthritis

The core treatments for osteoarthritis should focus on exercise, weight management, and patient education, with pharmacological treatments used as adjuncts when needed. 1, 2

Core Treatments (First-Line)

• Activity and exercise, including local muscle strengthening and general aerobic fitness, are essential for all patients with osteoarthritis to improve pain and function 1, 2
• Weight loss interventions should be implemented for all overweight or obese patients to reduce mechanical stress on weight-bearing joints 1, 2
• Patient education about osteoarthritis is crucial to enhance understanding and counter misconceptions that the condition is inevitably progressive 1, 2
• Self-management strategies emphasizing the recommended core treatments should be agreed upon with the patient 1

Non-Pharmacological Adjunct Treatments

• Local heat or cold applications provide temporary pain relief 1, 3
• Manipulation and stretching techniques are particularly beneficial for hip osteoarthritis 1, 4
• Transcutaneous electrical nerve stimulation (TENS) can help with pain management 1, 5
• Assessment for bracing, joint supports, or insoles should be considered for those with biomechanical joint pain or instability 1, 4
• Assistive devices (walking sticks, tap turners) should be provided for those with specific problems with activities of daily living 1, 2
• Appropriate footwear with shock-absorbing properties should be recommended 1, 2
• Pacing activities to avoid "peaks" and "troughs" of activity is important 1, 3

Pharmacological Treatment Algorithm

First-Line Medication

• Paracetamol (acetaminophen) should be tried first for pain relief, with regular dosing as needed 1, 2
• Topical NSAIDs should be considered for knee and hand osteoarthritis before oral NSAIDs, particularly for mild to moderate pain 1, 2

Second-Line Medication

• If paracetamol and topical NSAIDs are insufficient, consider oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period 1, 6
• When prescribing oral NSAIDs/COX-2 inhibitors, consider individual risk factors (including age) and add a proton pump inhibitor for gastroprotection 1, 6
• All oral NSAIDs have similar analgesic effects but vary in their potential gastrointestinal, liver, and cardiorenal toxicity 1, 6

Third-Line Medication

• Consider intra-articular corticosteroid injections for moderate to severe pain 1, 2
• Opioid analgesics may be considered if previous treatments are insufficient 1, 2

Important Considerations and Monitoring

• Risk assessment before NSAID use is essential, considering cardiovascular, gastrointestinal, and renal risk factors, especially in elderly patients 6
• Naproxen has been shown to be effective for osteoarthritis with less gastrointestinal bleeding and erosion than aspirin 6
• NSAIDs can cause serious side effects including ulcers and bleeding in the stomach and intestines, which may occur without warning and can be fatal 6
• Glucosamine and chondroitin products are not recommended based on current evidence 1, 2
• Electroacupuncture should not be used 1, 2
• Regular monitoring and periodic review of treatment effectiveness are essential as disease course and patient needs change over time 1, 2

When to Consider Referral for Surgical Intervention

• Referral for joint replacement surgery should be considered for patients with osteoarthritis who have joint symptoms (pain, stiffness, reduced function) that substantially impact their quality of life and are refractory to non-surgical treatment 1, 2
• Referral should be made before there is prolonged and established functional limitation and severe pain 1
• Patient-specific factors (including age, sex, smoking, obesity, and comorbidities) should not be barriers to referral for joint replacement surgery 1
• Arthroscopic lavage and debridement should not be routinely offered as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking 1

Common Pitfalls to Avoid

• Focusing solely on pharmacological treatments while neglecting core non-pharmacological interventions 1, 4
• Prescribing NSAIDs without considering individual risk factors or providing gastroprotection 6
• Delaying referral for surgical intervention until there is severe functional limitation 1
• Using treatments with insufficient evidence such as glucosamine, chondroitin, and electroacupuncture 1, 2
• Failing to regularly review and adjust treatment as the disease progresses 1, 2