What are the initial management recommendations for osteoarthritis?

Initial Management of Osteoarthritis

All patients with osteoarthritis should begin with three core non-pharmacological interventions: education and self-management strategies, an individualized exercise program, and weight loss if overweight or obese—these form the foundation before adding any pharmacological treatments. 1

Overarching Principles

The initial assessment must use a biopsychosocial approach, evaluating physical and psychological status, activities of daily living, participation including work, social determinants, and environmental factors. 1 Treatment decisions should be based on shared decision-making that considers the patient's needs, preferences, and capabilities. 1

Core Non-Pharmacological Interventions (Required for All Patients)

1. Education and Self-Management (First Priority)

• Provide information to counter misconceptions, particularly that osteoarthritis is inevitably progressive and cannot be treated. 1
• Include education on self-management strategies at the initial visit and reinforce at all subsequent clinical encounters. 1
• Teach self-efficacy programs that emphasize coping strategies and activity pacing. 1, 2

2. Exercise Programs (Second Priority)

• Offer an exercise program that includes strength training, aerobic exercise, flexibility, or neuromotor exercises (balance, coordination, tai chi, yoga). 1
• The program must have adequate dosage with progression tailored to physical function and preferences. 1
• Delivery mode (individual/group, supervised/unsupervised, face-to-face/digital, land-based/aquatic) should match local availability and patient preferences. 1
• Tai chi receives a strong recommendation specifically. 1

3. Weight Loss (Third Priority)

• For patients who are overweight or obese with knee and/or hip osteoarthritis, weight loss interventions are strongly recommended. 1
• Provide education on maintaining healthy weight and support to achieve and maintain weight loss. 1

Joint-Specific Non-Pharmacological Interventions

For Hand Osteoarthritis

• Strongly recommend first carpometacarpal (CMC) joint orthoses (neoprene or rigid, preferably custom-made) with long-term use of at least 3 months. 1, 3
• Conditionally recommend orthoses for other hand joints as disease progresses. 1, 3
• Provide joint protection education to minimize stress on affected joints. 3
• Apply local heat (paraffin wax, hot packs) especially before exercise. 3

For Knee Osteoarthritis

• Strongly recommend tibiofemoral bracing for tibiofemoral knee osteoarthritis. 1, 2
• Conditionally recommend patellofemoral bracing for patellofemoral osteoarthritis. 1, 2
• Strongly recommend cane use to improve mobility. 1, 2

For Hip Osteoarthritis

• Consider manipulation and stretching exercises. 1
• Strongly recommend cane use. 1, 2

Additional Non-Pharmacological Interventions to Consider

• Assistive devices (walking sticks, tap turners) for those with specific problems in activities of daily living. 1
• Appropriate footwear with shock-absorbing properties. 1
• Transcutaneous electrical nerve stimulation (TENS). 1
• Bracing, joint supports, or insoles for biomechanical joint pain or instability. 1
• Cognitive behavioral therapy (conditional recommendation). 1, 2
• Acupuncture (conditional recommendation). 1, 2

Pharmacological Management Algorithm

First-Line Pharmacological Treatment

For Knee and Hand Osteoarthritis:

• Start with topical NSAIDs (strongly recommended for knee, first-line for hand). 1, 3
• Alternatively, use paracetamol/acetaminophen at regular dosing up to 4,000 mg/day. 1, 4, 3

For Hip Osteoarthritis:

• Start with paracetamol/acetaminophen up to 4,000 mg/day. 1

Second-Line Pharmacological Treatment

If topical NSAIDs or paracetamol provide insufficient relief:

• Add or substitute oral NSAIDs at the lowest effective dose for the shortest duration. 1
• For patients ≥75 years old, strongly prefer topical NSAIDs over oral NSAIDs due to safety concerns. 1, 4, 3
• When prescribing oral NSAIDs, use either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID, both prescribed alongside a proton pump inhibitor. 1
• For patients with gastrointestinal risk factors, use a COX-2 selective inhibitor or a nonselective NSAID with a proton pump inhibitor. 4

Third-Line Pharmacological Treatment

• Intraarticular glucocorticoid injections for knee osteoarthritis (strongly recommended), particularly for acute flares with effusion. 1, 4
• For hand osteoarthritis, intraarticular corticosteroid injections are effective for painful flares, especially in the trapeziometacarpal joint. 3
• Conditionally recommend duloxetine or tramadol as alternatives. 1, 4

Additional Considerations for Knee Osteoarthritis

• Topical capsaicin is conditionally recommended. 1
• Radiofrequency ablation is conditionally recommended. 1

Treatments NOT Recommended

• Do not use glucosamine or chondroitin products. 1, 4
• Do not use electroacupuncture. 1
• Insufficient evidence exists to make a firm recommendation on traditional acupuncture, though it is conditionally recommended by some guidelines. 1

Work-Related Considerations

For patients with or at risk of work disability, offer timely advice on modifiable work-related factors and referral for expert advice where appropriate. 1

Behavioral Change Techniques

Consider employing elements of behavior change techniques when lifestyle modifications are needed (physical activity, weight loss). 1

Common Pitfalls and Caveats

• Splinting for hand osteoarthritis is most effective when used consistently for at least 3 months; shorter periods may not show significant benefit. 3
• Oral NSAIDs carry gastrointestinal, cardiovascular, and renal risks, particularly in elderly patients—always use the lowest effective dose for the shortest duration. 1
• Avoid combining NSAIDs with aspirin, as aspirin increases the rate of excretion of naproxen and the combination may result in higher frequency of adverse events. 5
• Exercise regimens for first CMC joint differ from those for interphalangeal joints and should be tailored accordingly. 3
• Regular monitoring and adjustment of the treatment plan is necessary given the progressive nature of osteoarthritis and potential comorbidities. 2