What are the management options for osteoarthritis?

Management of Osteoarthritis

Start all patients with exercise and weight loss (if overweight), add topical NSAIDs for knee OA, then progress to oral NSAIDs if needed, reserving intra-articular corticosteroids for flares and refractory symptoms. 1

Core Foundation for All Patients

Exercise Programs (Strongly Recommended)

• Implement supervised exercise as the cornerstone of treatment for hand, hip, and knee OA, including walking, strengthening exercises, neuromuscular training, and aquatic exercise with no hierarchy among these options. 2, 1
• Supervised exercise programs produce superior outcomes compared to unsupervised programs. 2
• Exercise should be continued long-term as benefits diminish when discontinued. 1

Weight Management (Strongly Recommended)

• Prescribe weight loss for all overweight or obese patients with knee and/or hip OA to reduce joint loading and improve symptoms. 2, 1
• Even 5-10% body weight reduction produces clinically meaningful symptom improvement. 1

Self-Management Education (Strongly Recommended)

• Provide structured self-efficacy and self-management programs to all patients covering disease understanding, coping strategies, and activity pacing. 2, 1

Joint-Specific Physical Interventions

Hand OA

• Apply rigid or neoprene first carpometacarpal (CMC) joint orthoses for first CMC joint OA (strongly recommended). 2, 1
• Consider orthoses for other hand joints beyond the first CMC (conditionally recommended). 2, 1

Knee OA

• Use tibiofemoral bracing for tibiofemoral OA (strongly recommended). 2, 1
• Apply patellofemoral bracing for isolated patellofemoral OA (conditionally recommended). 2, 1

Hip OA

• Prescribe cane use to improve mobility and reduce joint loading (strongly recommended). 1, 3

Pharmacological Treatment Algorithm

First-Line: Topical Therapy

• Apply topical NSAIDs for knee OA as first-line pharmacological treatment due to effective pain relief with minimal systemic exposure (strongly recommended). 1, 4
• Topical NSAIDs provide superior safety profile compared to oral formulations while maintaining efficacy. 1

Second-Line: Oral NSAIDs

• Prescribe oral NSAIDs for hand, knee, and hip OA when topical therapy is insufficient or impractical (strongly recommended). 2, 1, 5
• Use the lowest effective dose for the shortest duration to minimize gastrointestinal bleeding, cardiovascular events, and renal toxicity. 2, 1
• Assess cardiovascular disease, heart failure, gastrointestinal bleeding risk, hypertension, and chronic kidney disease before prescribing. 2
• Add proton pump inhibitor gastroprotection for patients at high gastrointestinal risk. 1
• Naproxen causes statistically significantly less gastric bleeding than aspirin at therapeutic doses. 5

Third-Line: Alternative Oral Agents

• Consider duloxetine for patients with inadequate response to NSAIDs or those with comorbid depression (conditionally recommended). 1, 4
• Consider acetaminophen for mild-to-moderate pain when NSAIDs are contraindicated, though recent evidence shows limited efficacy (conditionally recommended). 1, 4
• Reserve tramadol for refractory cases after other options have failed, recognizing dependence risks and side effects (conditionally recommended). 1, 4

Intra-Articular Injections

• Administer corticosteroid injections for knee and hip OA during acute flares or for short-term pain relief when oral medications are insufficient (strongly recommended). 1, 4
• Corticosteroid injections provide rapid symptom relief with relatively minor adverse effects. 4

Additional Therapeutic Modalities (Conditionally Recommended)

Physical Modalities

• Apply local heat or cold for symptomatic relief. 1
• Consider transcutaneous electrical nerve stimulation (TENS) for pain management. 1
• Use manipulation and stretching particularly for hip OA. 1

Mind-Body Interventions

• Incorporate yoga, cognitive behavioral therapy, or balance exercises for patients interested in integrative approaches. 1, 3
• These interventions may address comorbid mood disorders, sleep disturbances, and chronic pain that commonly accompany OA. 2

Treatments NOT Recommended

• Avoid glucosamine and chondroitin despite popular use, as evidence does not support efficacy. 1
• Do not use electroacupuncture based on current evidence. 1
• Avoid combining NSAIDs with aspirin as aspirin increases naproxen excretion and the combination increases adverse event frequency without demonstrated superior efficacy. 5

Critical Implementation Considerations

Comorbidity Assessment

• Screen for hypertension, cardiovascular disease, heart failure, gastrointestinal bleeding risk, and chronic kidney disease before finalizing pharmacological treatment plans. 2
• Evaluate disease severity, surgical history, and access to services (transportation, cost, insurance) when selecting physical therapy approaches. 2

Treatment Sequencing

• Begin with treatments having least systemic exposure or toxicity when choosing among pharmacological options. 2
• Use single interventions for mild disease, but employ multiple interventions in sequence or combination for moderate-to-severe symptoms. 2

Common Pitfalls

• Underutilization of exercise and weight management remains a major gap in OA care despite strong evidence. 6
• Overuse of opioid analgesics should be avoided; tramadol is only conditionally recommended for refractory cases. 6, 1
• Prolonged NSAID use without gastroprotection in high-risk patients increases serious gastrointestinal complications. 1

Shared Decision-Making

• Engage patients in treatment selection, particularly for conditional recommendations where benefits and harms are closely balanced. 2
• Address patient beliefs, preferences, and values when developing individualized treatment plans. 2