What are the treatment options for osteoarthritis?

Treatment Options for Osteoarthritis

The core treatment approach for osteoarthritis should prioritize non-pharmacological interventions including exercise therapy, weight loss if overweight, and patient education, followed by a stepped approach to pharmacological management starting with acetaminophen and topical NSAIDs before considering oral NSAIDs, with surgical options reserved for those with substantial impact on quality of life despite conservative management. 1, 2

Core Treatments (First-Line)

• Exercise therapy, including local muscle strengthening and general aerobic fitness, is essential for all patients with osteoarthritis to improve pain and function 1, 2
• Weight loss interventions for patients who are overweight or obese to reduce mechanical stress on weight-bearing joints 1
• Patient education to enhance understanding of the condition and counter misconceptions that osteoarthritis is inevitably progressive 1, 2
• Self-management strategies emphasizing the recommended core treatments, especially exercise 1, 3

Non-Pharmacological Adjunct Treatments

• Local heat or cold applications for temporary pain relief 1
• Manipulation and stretching, particularly beneficial for osteoarthritis of the hip 1, 3
• Transcutaneous electrical nerve stimulation (TENS) for pain management 1, 2
• Assessment for bracing, joint supports, or insoles for those with biomechanical joint pain or instability 1, 3
• Assistive devices (e.g., walking sticks) for those with specific problems with activities of daily living 1, 2

Pharmacological Treatment Algorithm

First-Line Medication

• Acetaminophen (paracetamol) 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 acetaminophen and topical NSAIDs are insufficient, consider oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period 1, 4
• When prescribing oral NSAIDs/COX-2 inhibitors, consider adding a proton pump inhibitor for gastroprotection, especially in high-risk patients 1, 4
• Carefully assess cardiovascular, gastrointestinal, and renal risk factors before prescribing NSAIDs, especially in elderly patients 1, 5

Third-Line Medication

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

Important Considerations and Monitoring

• NSAIDs can cause serious gastrointestinal adverse events including ulcers and bleeding, with increased risk in elderly patients, those taking corticosteroids or anticoagulants, and those with longer duration of use 5
• Regular monitoring of treatment effectiveness is essential as disease course and patient needs change over time 1, 2
• Avoid glucosamine and chondroitin products as they are not recommended based on current evidence 1, 2
• Electroacupuncture is not recommended based on current evidence 1

Surgical Considerations

• Referral for joint replacement surgery should be considered for patients with osteoarthritis who have joint symptoms (pain, stiffness, reduced function) that substantially affect quality of life despite comprehensive non-surgical treatment 1, 2
• Referral should be made before there is prolonged and established functional limitation and severe pain 1, 3
• Arthroscopic lavage and debridement should not be routinely offered as part of treatment for osteoarthritis, unless there is a clear history of mechanical locking 1, 6

Treatment Approach by Joint Type

• For knee and hand osteoarthritis, consider acetaminophen and/or topical NSAIDs as first-line pharmacological treatment 1, 2
• For hip osteoarthritis, manipulation and stretching may be particularly beneficial when combined with exercise therapy 1, 3
• For all joint types, exercise therapy remains the cornerstone of treatment, with specific exercises tailored to the affected joint 2, 7