What are the treatment options for osteoarthritis?

Osteoarthritis Treatment

All patients with osteoarthritis should receive three core treatments first: patient education, exercise (including muscle strengthening and aerobic fitness), and weight loss if overweight or obese—these are non-negotiable foundational interventions before considering any pharmacological therapy. 1

Core Non-Pharmacological Treatments (Mandatory for All Patients)

Patient Education

• Provide written and oral information to counter the misconception that osteoarthritis is inevitably progressive and untreatable 1
• Explain that the condition can be managed effectively with appropriate interventions 1

Exercise Therapy

• Prescribe local muscle strengthening exercises targeting affected joints 1, 2
• Include general aerobic fitness training regardless of age, disease severity, pain level, or comorbidities 2, 3
• Consider both land-based and aquatic exercises 2

Weight Management

• Implement weight loss interventions for all overweight or obese patients 1, 2
• Even modest weight loss (5-10% of body weight) significantly reduces joint pain and mechanical stress on weight-bearing joints 2, 4

Pharmacological Treatment Algorithm

First-Line: Simple Analgesics

• Start with acetaminophen (paracetamol) at regular dosing up to 4,000 mg/day for mild to moderate pain 1, 5
• For knee and hand osteoarthritis specifically, consider topical NSAIDs before oral NSAIDs 1
• Topical capsaicin can be added for additional pain relief 1

Second-Line: Oral NSAIDs/COX-2 Inhibitors

• If acetaminophen and topical NSAIDs provide insufficient relief, escalate to oral NSAIDs or COX-2 inhibitors 1
• Always prescribe at the lowest effective dose for the shortest possible duration 1
• Mandatory co-prescription: Add a proton pump inhibitor (choose lowest cost option) with any oral NSAID or COX-2 inhibitor 1
• First choice should be either a COX-2 inhibitor (excluding etoricoxib 60 mg) or a standard NSAID 1

Critical Safety Consideration: Before prescribing NSAIDs, assess cardiovascular, gastrointestinal, renal, and hepatic risk factors, particularly in elderly patients 1, 2. All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but differ significantly in toxicity profiles 1.

Third-Line: Opioid Analgesics

• Consider adding opioid analgesics only if paracetamol and topical NSAIDs are insufficient 1
• Can be used in combination with paracetamol 1

Intra-Articular Injections

• Corticosteroid injections are indicated for moderate to severe pain, particularly effective for joint effusion 1, 6
• Provide short-term pain relief during disease flares 7

Adjunct Non-Pharmacological Interventions

Physical Modalities

• Local heat or cold applications for temporary pain relief 1, 2
• Transcutaneous electrical nerve stimulation (TENS) for pain management 1
• Manual therapy (manipulation and stretching), particularly beneficial for hip osteoarthritis 1

Biomechanical Support

• Appropriate footwear with shock-absorbing properties 1, 2
• Assessment for bracing, joint supports, or insoles in patients with biomechanical joint pain or instability 1
• Walking aids and assistive devices (e.g., walking sticks, tap turners) for those with specific functional limitations 1, 2

Behavioral Modifications

• Activity pacing to avoid "peaks and troughs" of activity 1
• Self-management strategies emphasizing core treatments 1

What NOT to Use

Do not recommend the following interventions:

• Glucosamine and chondroitin products (insufficient evidence) 1, 2
• Electroacupuncture (should not be used) 1
• Routine arthroscopic lavage and debridement (unless clear mechanical locking in knee OA) 1

Surgical Referral Criteria

Refer for joint replacement surgery when:

• Joint symptoms (pain, stiffness, reduced function) substantially affect quality of life 1, 2
• Symptoms are refractory to comprehensive non-surgical treatment including core interventions 1
• Refer before prolonged and established functional limitation develops 1

Important: Age, sex, smoking, obesity, and comorbidities should NOT be barriers to surgical referral 1

Monitoring and Follow-Up

• Provide periodic review tailored to individual needs, as disease course and requirements change over time 1, 8
• Assess ongoing impact on function, quality of life, occupation, mood, relationships, and leisure activities 1
• Monitor for NSAID-related renal, hepatic, and gastrointestinal toxicity, especially in elderly patients 1, 4
• Formulate management plans in partnership with the patient, considering comorbidities 1

Common Pitfalls to Avoid

• Never skip core treatments: Pharmacological interventions are adjuncts, not replacements, for education, exercise, and weight management 1
• Avoid long-term NSAID use without gastroprotection: Always co-prescribe a proton pump inhibitor 1
• Don't delay surgical referral: Refer before severe functional limitation becomes established 1
• Avoid polypharmacy with NSAIDs: Do not combine with other NSAIDs or use with low-dose aspirin without careful consideration and gastroprotection 1