What are the recommended treatments for managing osteoarthritis pain?

Osteoarthritis Pain Management

For osteoarthritis pain, begin with education, exercise (including strength training and aerobic activity), and weight loss if overweight, then add topical NSAIDs as first-line pharmacological therapy before considering oral NSAIDs or other systemic medications. 1

Core Treatment Foundation (Required for All Patients)

These interventions form the foundation and should be implemented before or alongside any pharmacological therapy:

Patient Education

• Provide both oral and written information to counter the misconception that osteoarthritis is inevitably progressive and untreatable 1
• Education demonstrates uniform positive effects on pain across hip/knee and isolated knee OA 1

Physical Activity and Exercise

• Exercise shows the most uniformly positive effects on pain across all treatment modalities 1
• Implement general exercise programs that include local muscle strengthening and general aerobic fitness 1, 2
• Aerobic exercise demonstrates positive effects specifically for general OA and knee OA 1
• Strength and resistance training shows uniform positive effects for general OA, hip/knee OA, isolated hip OA, and isolated knee OA 1
• For foot/ankle OA specifically, general exercise programs are effective 1

Weight Management

• Weight loss is mandatory if the patient is overweight or obese 1, 2
• Weight management demonstrates uniform positive effects on pain in hip/knee OA 1
• This reduces mechanical stress on affected joints 2

Footwear Modifications

• Recommend shoes with shock-absorbing properties to reduce joint loading 1, 2
• This is particularly important for lower extremity OA 2

Adjunct Non-Pharmacological Treatments

Psychological Interventions

• Psychological interventions show uniformly positive effects on pain, second only to exercise 1
• Cognitive behavioral therapy (CBT) demonstrates uniform positive effects for general OA 1
• Psychosocial and coping interventions are effective for general OA 1
• Relaxation interventions show positive effects for general OA and hip/knee OA 1

Orthotics and Assistive Devices

• Orthotics show small but consistent positive effects on pain 1
• For knee OA: knee orthoses (especially sleeves and elastic bandages) are effective 1
• For hand OA: splints demonstrate positive effects 1
• For foot OA: insoles or orthoses benefit patients with biomechanical joint pain or instability 1, 2
• Consider assistive devices (walking sticks, tap turners) for patients with specific functional limitations 1, 2

Physical Modalities

• Local heat or cold applications may provide symptomatic relief 1, 2
• Transcutaneous electrical nerve stimulation (TENS) can be considered 1
• Manipulation and stretching, particularly for hip OA, may be beneficial 1

Interventions NOT Recommended

• Do NOT use glucosamine or chondroitin products 1
• Do NOT use electroacupuncture 1, 2
• Insufficient evidence exists for acupuncture despite some trials 1

Pharmacological Treatment Algorithm

First-Line: Topical Therapy

• For knee and hand OA, topical NSAIDs are the first-line pharmacological treatment 1, 2
• Topical NSAIDs (such as diclofenac) have fewer systemic side effects than oral NSAIDs 2
• Topical capsaicin can also be considered 1

Second-Line: Oral Analgesics

• Paracetamol (acetaminophen) can be offered for pain relief with regular dosing as needed 1, 2
• Consider paracetamol before advancing to oral NSAIDs or COX-2 inhibitors 1

Third-Line: Oral NSAIDs/COX-2 Inhibitors

• If paracetamol and topical NSAIDs provide insufficient pain relief, add or substitute with oral NSAIDs or COX-2 inhibitors 1, 2
• Use the lowest effective dose for the shortest possible duration 1, 3
• Always co-prescribe a proton pump inhibitor for gastroprotection, choosing the one with the lowest acquisition cost 1, 2
• First choice should be either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID 1

Fourth-Line: Opioid Analgesics

• Consider adding opioid analgesics if NSAIDs are insufficient or contraindicated 1

Intra-articular Injections

• Intra-articular corticosteroid injections may provide short-term pain relief during disease flares 1, 4
• Hyaluronic acid products can be considered for knee OA 4

Critical Safety Considerations

NSAID Risk Assessment

• All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but vary significantly in gastrointestinal, hepatic, and cardiorenal toxicity 1, 2
• Assess individual risk factors including age before prescribing 1
• For elderly patients (≥75 years), topical NSAIDs are strongly preferred over oral NSAIDs when applicable 3
• Assess cardiovascular risk factors, particularly uncontrolled hypertension, before prescribing 3
• Use with caution in patients with mild to moderate renal impairment 3
• Consider ongoing monitoring of gastrointestinal, hepatic, and renal function 1

Special Populations

• In elderly patients and those with comorbidities, carefully weigh risks and benefits of all pharmacological treatments 1
• For patients taking low-dose aspirin, consider alternative analgesics to avoid increased gastrointestinal risk 1

Assessment and Monitoring

Initial Assessment

• Evaluate the effect of OA on function, quality of life, occupation, mood, relationships, and leisure activities 1
• Assess pain characteristics, previous and ongoing pain treatments, inflammation and joint damage, and psychological factors 1
• Identify patient needs, preferences, and priorities 1

Ongoing Management

• Provide periodic review tailored to individual needs 1
• Formulate management plans in partnership with the patient, considering comorbidities 1
• Target positive behavioral changes including exercise, weight loss, appropriate footwear, and activity pacing (avoiding "peaks and troughs") 1

Common Pitfalls to Avoid

• Do not skip core non-pharmacological treatments (education, exercise, weight management) in favor of medications alone—these have the strongest and most uniform evidence for pain reduction 1
• Do not prescribe oral NSAIDs without gastroprotection in patients requiring chronic use 1, 2
• Do not use NSAIDs in combination with aspirin without careful consideration of increased gastrointestinal risk 1
• Do not recommend glucosamine, chondroitin, or electroacupuncture as these lack evidence of benefit 1, 2
• Do not neglect psychological interventions—these show uniformly positive effects comparable to exercise 1