What is the recommended oral corticosteroid (CS) dose for osteoarthritis (OA)?

Oral Corticosteroid Dosing for Osteoarthritis

Oral corticosteroids are not recommended for the management of osteoarthritis as they are not included in current treatment guidelines and have unfavorable risk-benefit profiles compared to other available treatments.

Recommended Treatment Approach for Osteoarthritis

First-Line Treatments

• Begin with non-pharmacological core treatments including exercise, weight loss if overweight, and use of suitable footwear with shock-absorbing properties 1
• For pharmacological management, start with:
  • Paracetamol (acetaminophen) for short-term use at ≤3 g/day 1
  • Topical NSAIDs for knee and hand osteoarthritis 1

Second-Line Treatments

• If first-line treatments are insufficient:
  • Oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period 1
  • Use with caution in patients with cardiovascular, gastrointestinal, or renal risk factors 1
  • Consider adding a proton pump inhibitor when using oral NSAIDs 1
• Duloxetine may be considered as an alternative or adjunct to initial treatments 1

Intra-articular Corticosteroid Injections

• Intra-articular corticosteroid injections are strongly recommended for knee and hip OA and conditionally recommended for hand OA 1
• These provide short-term relief (1-4 weeks) and are particularly effective for acute exacerbations of pain 2, 3
• Ultrasound guidance is strongly recommended for hip joint injections 1
• Benefits typically last for 1-4 weeks with minimal evidence for longer-term benefits 2, 3

Important Considerations

Safety Concerns

• Oral corticosteroids are not included in current treatment guidelines for osteoarthritis management 1
• Long-term use of oral NSAIDs and intra-articular corticosteroids can lead to negative side effects 4
• For intra-articular corticosteroids, there are concerns that frequent injections may contribute to cartilage loss, though the clinical significance remains uncertain 1

Contraindications and Precautions

• Oral NSAIDs should generally be avoided in patients with or at risk for cardiovascular disease, chronic kidney disease, and serious upper gastrointestinal toxicity 1
• NSAIDs should be avoided in patients with eGFR <30 ml/min per 1.73 m² 1
• Corticosteroid injections should be avoided within 3 months prior to knee replacement surgery 1

Treatment Alternatives

• Opioids, including tramadol, are not recommended for managing OA pain due to limited benefit and high risk of adverse effects 1
• Intra-articular hyaluronic acid may be considered for patients with contraindications to NSAIDs or those still symptomatic despite NSAID use 1

Conclusion for Clinical Practice

When treating osteoarthritis, focus on non-pharmacological approaches first, followed by topical and oral NSAIDs for short-term use. For acute flares with significant pain and inflammation, intra-articular corticosteroid injections provide effective short-term relief. Oral corticosteroids should not be used for osteoarthritis management as they are not supported by current guidelines and carry significant risks without established benefits for this condition.