What are the treatment options for osteoarthritis?

Medical Treatment for Osteoarthritis

The optimal management of osteoarthritis requires a comprehensive approach including core treatments of exercise, weight management, and patient education, supplemented with appropriate pharmacological interventions such as acetaminophen, NSAIDs, and intra-articular injections based on symptom severity and individual risk factors. 1, 2

Core Treatments (First-Line)

• Regular exercise programs, including walking, strengthening exercises, and aquatic exercise, are essential to improve pain and function in all patients with osteoarthritis 2
• Weight loss interventions should be implemented for 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 3

Non-Pharmacological Adjunct Treatments

Physical Modalities

• Local heat or cold applications can provide temporary pain relief 3
• Transcutaneous electrical nerve stimulation (TENS) can be used for pain management 3
• Manipulation and stretching are particularly beneficial for hip osteoarthritis 3

Assistive Devices and Supports

• Bracing is recommended for knee osteoarthritis (tibiofemoral braces for tibiofemoral OA, patellofemoral braces for patellofemoral OA) 2
• For hand osteoarthritis, first carpometacarpal joint orthoses are strongly recommended 2
• Assistive devices (walking sticks, tap turners) should be considered for those with specific functional limitations 3
• Appropriate footwear with shock-absorbing properties can reduce joint stress 3

Pharmacological Treatment Algorithm

First-Line Medications

• Acetaminophen (paracetamol) should be tried first for pain relief, with regular dosing as needed (up to 4,000 mg/day) 3, 1
• Topical NSAIDs are recommended before oral NSAIDs, particularly for knee and hand osteoarthritis 3, 2

Second-Line Medications

• If acetaminophen and topical NSAIDs are insufficient, consider oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period 3, 2
• When prescribing oral NSAIDs/COX-2 inhibitors, add a proton pump inhibitor for gastroprotection, especially in elderly patients 3
• Naproxen has been shown to be effective in controlling osteoarthritis symptoms with potentially fewer gastrointestinal and nervous system adverse effects compared to aspirin or indomethacin 4

Third-Line Medications

• Duloxetine is recommended for patients with inadequate response to first-line treatments or with comorbid depression 2
• Tramadol can be considered when other options have failed, but carries risks of dependence and side effects 2

Intra-articular Treatments

• Corticosteroid injections are recommended for knee and hip osteoarthritis for short-term pain relief during flares 2

Important Considerations and Caveats

• Risk assessment before NSAID use is essential, considering cardiovascular, gastrointestinal, and renal risk factors, especially in elderly patients 3, 1
• NSAIDs should be used at the lowest effective dose for the shortest duration due to potential side effects 4
• Regular monitoring of treatment effectiveness is essential as disease course and patient needs change over time 1
• The combination of NSAIDs with aspirin is not recommended as aspirin may increase the excretion of NSAIDs and the combination may result in higher frequency of adverse events 4

Treatments Not Recommended

• Glucosamine and chondroitin products are not recommended based on current evidence 3, 2
• Electroacupuncture should not be used 3

Treatment Progression

1. Start with core treatments for all patients (exercise, weight loss if needed, education) 1, 2
2. Add physical modalities and assistive devices based on joint involvement 3, 2
3. Begin with acetaminophen and/or topical NSAIDs for pain management 3, 2
4. Progress to oral NSAIDs with gastroprotection if initial treatments are inadequate 3, 2
5. Consider duloxetine or tramadol for refractory cases 2
6. Use intra-articular corticosteroid injections for flares or persistent symptoms 2
7. Consider referral for surgical evaluation when conservative measures fail to provide adequate pain relief and functional improvement 1