What are the treatment options for osteoarthritis?

Treatment for Osteoarthritis

Begin with exercise therapy and weight loss (if overweight/obese) as the foundation, add topical NSAIDs for knee/hand OA, then progress to oral NSAIDs if needed, reserving intra-articular corticosteroid injections for flares and joint replacement for severe refractory disease. 1, 2

Core First-Line Treatments (Start Here for All Patients)

Exercise programs are mandatory and include land-based walking, strengthening exercises, neuromuscular training, and aquatic exercise to improve both pain and function. 1, 2, 3 This is strongly recommended by the American College of Rheumatology regardless of joint involvement (hand, hip, or knee). 2, 3

Weight loss is non-negotiable for overweight or obese patients with knee and/or hip OA, as it directly reduces mechanical stress on weight-bearing joints. 1, 2, 3 The American College of Rheumatology gives this a strong recommendation. 2

Patient education and self-management programs must be provided to counter misconceptions about the disease and develop effective coping strategies. 1, 2, 3

Pharmacological Treatment Algorithm

Step 1: Topical Therapy First

Topical NSAIDs are the first-line pharmacological treatment for knee and hand OA, providing effective pain relief with minimal systemic exposure and fewer side effects than oral medications. 1, 2, 3 This is strongly recommended by multiple guidelines. 2

Step 2: Oral Medications if Topical Therapy Insufficient

Oral NSAIDs are strongly recommended for hand, knee, and hip OA when topical therapy is inadequate, but must be used at the lowest effective dose for the shortest duration. 2, 3 Naproxen has demonstrated efficacy comparable to aspirin and indomethacin but with less frequent gastrointestinal and nervous system adverse effects (nausea, dyspepsia, tinnitus, dizziness). 4

Critical risk assessment before NSAID use: Evaluate cardiovascular risk factors (NSAIDs increase risk of MI and stroke, especially with longer use), gastrointestinal risk (ulcers and bleeding can occur without warning), and renal function, particularly in elderly patients. 1, 4 NSAIDs are contraindicated immediately before or after coronary artery bypass graft surgery. 4

Acetaminophen (up to 4,000 mg/day) is conditionally recommended for mild to moderate pain, though recent guidelines have downgraded its importance due to limited efficacy compared to NSAIDs. 1, 2 Monitor for hepatotoxicity with regular dosing. 1

Step 3: Second-Line Oral Medications

Duloxetine is conditionally recommended for patients with inadequate response to first-line treatments or those with comorbid depression. 2

Tramadol is conditionally recommended only when other options have failed, but carries significant risks of dependence and side effects. 2 Reserve this for refractory cases. 2

Step 4: Intra-Articular Injections

Corticosteroid injections are strongly recommended for knee and hip OA to provide short-term pain relief during flares or for persistent symptoms despite oral therapy. 2

Joint-Specific Non-Pharmacological Interventions

Hand OA

• First carpometacarpal (CMC) joint orthoses are strongly recommended 2, 3
• Orthoses for other hand joints and kinesiotaping are conditionally recommended 2, 3

Knee OA

• Tibiofemoral bracing is strongly recommended for tibiofemoral OA 2, 3
• Patellofemoral bracing is conditionally recommended for patellofemoral OA 2, 3

Hip OA

• Cane use is strongly recommended to improve mobility and reduce joint load 2, 3

Adjunctive Physical Modalities

Local heat or cold applications, transcutaneous electrical nerve stimulation (TENS), and manual therapy can provide temporary symptomatic relief. 1, 2 For hip OA specifically, manipulation and stretching are particularly beneficial. 2

Treatments to AVOID

Do not recommend glucosamine or chondroitin supplements—they have not shown significant benefits over placebo despite popular use. 1, 2

Do not recommend electroacupuncture—current evidence does not support its use. 1, 2

Surgical Intervention

Joint replacement surgery should be considered when conservative measures (exercise, weight loss, pharmacological treatments, and injections) fail to provide adequate pain relief and functional improvement. 1 This is reserved for severe osteoarthritis. 1

Critical Implementation Points

The treatment course must be escalated systematically: start with core treatments (exercise, weight loss, education), add joint-specific orthoses/bracing, progress to topical NSAIDs for accessible joints, then oral NSAIDs if response is inadequate, reserve tramadol for refractory cases, and use intra-articular injections for persistent symptoms or flares. 2

Common pitfall: Avoid combining naproxen with aspirin, as aspirin increases naproxen excretion rates and the combination increases adverse event frequency without demonstrated superior efficacy. 4 The combination of NSAIDs with corticosteroids and anticoagulants significantly increases bleeding risk. 4

Regular monitoring and periodic review of treatment effectiveness are essential, as disease progression and patient needs change over time. 1