What are the current treatment options for osteoarthritis (OA)?

Current Treatment Options for Osteoarthritis

All patients with osteoarthritis should begin with core non-pharmacological treatments—exercise, weight loss if overweight/obese, and self-management education—before adding pharmacological therapies in a stepwise manner based on symptom severity and joint involvement. 1

Core Treatments (Foundation for All Patients)

Non-Pharmacological Interventions

• Exercise programs are strongly recommended for all OA patients, including walking, strengthening exercises, aquatic exercise, and neuromuscular training to improve pain and function 1, 2
• Weight loss is strongly recommended for overweight or obese patients with knee and/or hip OA to reduce joint load and improve symptoms 1, 2
• Self-management and education programs should be provided to all patients to enhance understanding of the condition, counter misconceptions (such as OA being inevitably progressive), and develop coping strategies 3, 1

These core treatments form the foundation and should be offered to every patient regardless of disease severity, as they improve morbidity and quality of life with minimal risk 3.

Joint-Specific Physical Interventions

Hand OA

• First carpometacarpal (CMC) joint orthoses are strongly recommended for thumb base OA, with custom-made rigid or neoprene splints preferred for optimal fit and compliance 1, 4
• Long-term use (at least 3 months) is necessary for optimal symptom relief—shorter periods show minimal benefit 4
• Orthoses for other hand joints are conditionally recommended as disease progresses 1, 4

Knee OA

• Tibiofemoral bracing is strongly recommended for tibiofemoral OA 1, 2
• Patellofemoral bracing is conditionally recommended for patellofemoral OA 1, 2
• Cane use is strongly recommended to improve mobility and reduce joint load 1, 2

Hip OA

• Cane use is strongly recommended to reduce load on affected joints 1
• Manipulation and stretching are particularly beneficial for hip OA 3

Additional Physical Modalities

• Local heat or cold applications can provide symptomatic relief 3, 1
• Transcutaneous electrical nerve stimulation (TENS) can be used for pain relief 3, 1
• Balance exercises and yoga are conditionally recommended 1, 2

Pharmacological Treatment Algorithm

First-Line Pharmacological Treatment

• Topical NSAIDs are strongly recommended as first-line pharmacological treatment for knee OA, providing effective pain relief with minimal systemic exposure 1, 4
• For hand OA, topical NSAIDs are preferred over systemic treatments due to safety considerations, especially when only a few joints are affected 4

Second-Line Pharmacological Treatment

• Oral NSAIDs are strongly recommended for hand, knee, and hip OA when topical treatments are insufficient 1, 2
• Use at the lowest effective dose for the shortest duration due to gastrointestinal, cardiovascular, and renal risks 3, 1
• Co-prescribe a proton pump inhibitor with oral NSAIDs or COX-2 inhibitors 3
• In patients ≥75 years, topical rather than oral NSAIDs are recommended due to safety concerns 4

Important caveat: While older guidelines recommended paracetamol (acetaminophen) as first-line treatment 3, recent evidence has downgraded its importance due to limited efficacy, and it is now only conditionally recommended for mild to moderate pain 1.

Third-Line Pharmacological Treatment

• Duloxetine is conditionally recommended for patients with inadequate response to first-line treatments or with comorbid depression 1, 2
• Tramadol is conditionally recommended when other options have failed, but carries risks of dependence and side effects—reserve for refractory cases 1, 2

Intra-Articular Injections

• Corticosteroid injections are strongly recommended for knee and hip OA for short-term pain relief during flares 1, 2
• For hand OA, intra-articular corticosteroid injection is effective for painful flares, especially in the trapeziometacarpal joint 4

Treatments NOT Recommended

• Glucosamine and chondroitin products are not recommended despite popular use 3, 1
• Electroacupuncture should not be used 3, 1
• Lateral heel wedges should not be prescribed for medial compartmental knee OA 3
• Arthroscopic lavage or débridement should not be routinely performed 3

Surgical Considerations

• Partial meniscectomy or loose body removal may be considered as conditions warrant 3
• Realignment osteotomy may be considered for appropriate candidates 3
• For severe thumb base OA, surgical options (interposition arthroplasty, osteotomy, or arthrodesis) should be considered when conservative treatments have failed and patients have marked pain and/or disability 4
• Joint replacement surgery should be reserved for severe OA unresponsive to comprehensive medical management 3

Stepwise Treatment Algorithm

1. Start with core treatments for all patients: exercise, weight loss (if applicable), and self-management education 1, 2
2. Add physical modalities based on joint involvement: appropriate bracing, orthoses, and assistive devices 1, 2
3. Add topical therapies for accessible joints, especially knees, using topical NSAIDs 1, 2
4. Progress to oral medications if inadequate response: start with oral NSAIDs at the lowest effective dose; consider duloxetine if NSAIDs are contraindicated 1
5. Reserve tramadol for refractory cases 1, 2
6. Consider intra-articular injections for persistent symptoms or flares 1, 2

Common Pitfalls

• Failing to emphasize core non-pharmacological treatments—these improve quality of life and should never be omitted 3, 1
• Using oral NSAIDs without gastroprotection in at-risk patients 3
• Prescribing glucosamine/chondroitin despite lack of evidence 3, 1
• Discontinuing orthoses too early (before 3 months) in hand OA 4
• Referring for arthroscopic procedures that lack evidence of benefit 3