What are the treatment options for osteoarthritis?

Treatment Options for Osteoarthritis

The most effective treatment approach for osteoarthritis includes core interventions of exercise therapy, weight loss for overweight patients, and patient education, supplemented by appropriate pharmacological treatments based on symptom severity and individual risk factors. 1

Core Treatments (First-Line)

• Exercise therapy is essential for all patients with osteoarthritis, including both muscle strengthening and general aerobic fitness activities to improve pain and function 2, 1
• Weight loss interventions should be implemented for all overweight or obese patients to reduce mechanical stress on weight-bearing joints 2, 1
• Patient education should provide appropriate information to enhance understanding of the condition and counter misconceptions (such as osteoarthritis being inevitably progressive) 2, 1
• Self-management strategies should be developed in partnership with patients, emphasizing the core treatments, especially exercise 2, 3

Non-Pharmacological Adjunct Treatments

• Local heat or cold applications can provide temporary pain relief 2, 1
• Manipulation and stretching techniques are particularly beneficial for hip osteoarthritis 2, 3
• Transcutaneous electrical nerve stimulation (TENS) can be used for pain management 2, 1
• Bracing, joint supports, or insoles should be considered for those with biomechanical joint pain or instability 2, 3
• Assistive devices (e.g., walking sticks) should be provided for those with specific problems with activities of daily living 2, 1
• Appropriate footwear with shock-absorbing properties should be recommended 2, 3
• Activity pacing to avoid "peaks" and "troughs" of activities should be encouraged 2, 3

Pharmacological Treatment Algorithm

First-Line Medication

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

Second-Line Medication

• If paracetamol or topical NSAIDs are insufficient, consider oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period 2, 1
• When prescribing oral NSAIDs/COX-2 inhibitors, add a proton pump inhibitor for gastroprotection, choosing the one with the lowest acquisition cost 2
• Consider individual risk factors (including age) for cardiovascular, gastrointestinal, and renal toxicity when selecting the specific NSAID and dose 2, 4

Third-Line Medication

• Consider adding opioid analgesics if previous treatments are insufficient 2, 1

Important Considerations and Caveats

• Regular monitoring and periodic review of treatment effectiveness are essential as disease progression and patient needs change over time 2, 1
• Avoid glucosamine and chondroitin products as they are not recommended based on current evidence 2, 5
• Electroacupuncture should not be used, and there is insufficient evidence to recommend traditional acupuncture 2
• NSAIDs have been shown to cause less gastric bleeding and erosion than high-dose aspirin in clinical studies 4
• The combination of naproxen with salicylates is not recommended due to evidence that aspirin increases the rate of excretion of naproxen 4
• Surgical interventions should be avoided initially, with joint replacement surgery considered only for severe osteoarthritis that has not responded to comprehensive non-surgical management 5, 6
• Obesity is the most important modifiable risk factor for osteoarthritis, making weight loss a critical intervention 5, 7
• Land- and water-based exercises are both effective for managing osteoarthritis symptoms 5, 8

Treatment Approach Based on Disease Severity

• For mild symptoms: Focus on core treatments (exercise, weight loss if needed, education) with paracetamol or topical NSAIDs as needed 2, 1
• For moderate symptoms: Continue core treatments while adding oral NSAIDs with gastroprotection, considering individual risk factors 2, 6
• For severe symptoms: Maintain core treatments while optimizing pharmacological management; consider referral for surgical evaluation if symptoms substantially impact quality of life despite comprehensive management 1, 6