What are the treatment options for Osteoarthritis (OA) and Polymyalgia Rheumatica (PMR)?

Treatment for Osteoarthritis and Polymyalgia Rheumatica

Osteoarthritis Management

Begin with exercise as the foundation of treatment, followed by topical NSAIDs for localized knee OA or oral NSAIDs for polyarticular disease, while acetaminophen should be avoided as it lacks efficacy. 1

Non-Pharmacologic Interventions (First-Line)

• Exercise is strongly recommended for all patients with knee, hip, or hand OA and should be initiated immediately 1
• Weight loss is strongly recommended for patients with knee or hip OA who are overweight or obese 1
• Self-efficacy and self-management programs are strongly recommended 1
• Physical and occupational therapy referral is beneficial for exercise instruction, self-management training, thermal therapies, and fitting of splints/braces 1
• Tai chi is strongly recommended as an effective exercise modality 1

Pharmacologic Treatment Algorithm

Start with agents having the least systemic exposure or toxicity 1

For Localized Knee OA:

• Topical NSAIDs are strongly recommended as first-line pharmacologic therapy 1
• Topical capsaicin is conditionally recommended as an alternative 1

For Hip OA or Polyarticular Disease:

• Oral NSAIDs are strongly recommended at the lowest effective dose for the shortest duration 1
• Use gastroprotective agents (proton pump inhibitors) in patients at high risk for GI bleeding 1
• Assess cardiovascular disease, hypertension, heart failure, chronic kidney disease, and GI bleeding risk before prescribing 1

Additional Pharmacologic Options:

• Intra-articular glucocorticoid injections are strongly recommended for knee or hip OA 1
• Duloxetine is conditionally recommended for patients with concurrent mood disorders or chronic widespread pain 1
• Tramadol is conditionally recommended when other options are inadequate 1
• Acetaminophen should not be used as it lacks efficacy compared to placebo in rigorous trials 2

Adjunctive Interventions

• Cane use is strongly recommended for ambulation assistance 1
• First CMC joint orthoses are strongly recommended for hand OA 1
• Tibiofemoral bracing is strongly recommended for knee OA 1
• Acupuncture, kinesiotaping, and thermal modalities are conditionally recommended 1

Common Pitfalls

• Do not rely on acetaminophen as primary therapy—it has been shown ineffective in placebo-controlled trials despite widespread recommendations 2
• Address comorbid mood disorders, sleep disturbances, and chronic pain with a multimodal approach rather than single medication 1
• Avoid high molecular weight intra-articular hyaluronan in patients with concurrent CPPD as it may trigger acute attacks 1

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Polymyalgia Rheumatica Management

Initiate prednisone 12.5-25 mg daily immediately after diagnostic workup, with higher doses within this range for patients at high relapse risk and low adverse event risk. 1, 3

Diagnostic Workup (Before Treatment)

Obtain the following baseline laboratory tests 1, 3:

• Rheumatoid factor and/or anti-CCP antibodies to exclude rheumatoid arthritis
• CRP and/or ESR (typically elevated in PMR)
• Complete blood count, glucose, creatinine, liver function tests
• Bone profile (calcium, alkaline phosphatase) and urinalysis
• Consider protein electrophoresis, TSH, creatine kinase, vitamin D

Assess comorbidities that increase glucocorticoid risk 1, 3:

• Hypertension, diabetes, cardiovascular disease, dyslipidemia
• Osteoporosis (especially recent fractures), peptic ulcer disease
• Cataracts, glaucoma risk factors, chronic infections
• Current NSAID use

Initial Treatment

Prednisone 12.5-25 mg daily is strongly recommended over NSAIDs 1, 4

• Use higher initial doses (20-25 mg) for patients with high ESR (>40 mm/hr), peripheral inflammatory arthritis, or female sex (relapse risk factors) 1, 3
• NSAIDs may be used short-term only for pain related to other conditions, not as primary PMR therapy 1

Glucocorticoid Tapering Schedule

After achieving symptom control (usually 4-10 days) 1:

• Reduce to 10 mg daily over 4-8 weeks
• Then decrease by 1 mg every 4 weeks (or use alternating schemes like 10/7.5 mg every other day) 5
• Taper rate should not exceed 1 mg per month once below 10 mg daily 5

Management of Relapses

For relapses on ≤5 mg prednisone, return to the previous effective dose 5

• Re-establish symptom control, then reduce over 4-8 weeks to the dose at which relapse occurred 5
• Subsequent tapering should be slower than initial schedule (1 mg per month maximum) 5
• For persistent nighttime pain when reducing below 5 mg/day, consider splitting the daily dose 5

Glucocorticoid-Sparing Agents

Methotrexate is conditionally recommended for patients with multiple relapses, prolonged therapy requirements, or high glucocorticoid-related adverse event risk 1, 6

• Typical dose: 5-10 mg/week 1
• Monitor for hepatotoxicity, bone marrow suppression, and pulmonary toxicity 7

Tocilizumab and sarilumab (anti-IL-6 receptor agents) are emerging options that reduce relapse frequency, lower cumulative glucocorticoid burden, and achieve long-term remission 6

• Consider for refractory disease or patients with significant glucocorticoid contraindications 6
• Anti-TNF agents have failed to show benefit in isolated PMR 6

Monitoring Schedule

• Every 4-8 weeks during the first year of treatment 1, 3, 5
• Every 8-12 weeks in the second year 1
• Monitor inflammatory markers (ESR, CRP) and clinical symptoms at each visit 5
• Systematically evaluate for glucocorticoid-related adverse effects, comorbidities, and relapse risk factors 5

Specialist Referral Indications

Refer to rheumatology for 1, 3:

• Atypical presentation (peripheral inflammatory arthritis, systemic symptoms, low inflammatory markers, age <60 years)
• High risk of or existing glucocorticoid-related adverse effects
• PMR refractory to glucocorticoid therapy
• Multiple relapses or prolonged therapy requirements

Common Pitfalls

• Do not use NSAIDs as primary therapy—they are ineffective for PMR and delay appropriate treatment 1, 8
• Female sex is associated with higher risk of both glucocorticoid side effects and disease relapse 1, 3
• Avoid rapid tapering below 10 mg daily, as this significantly increases relapse risk 5
• Consider that some patients may develop PMR-like syndromes (particularly with immune checkpoint inhibitor therapy) without classic pelvic girdle involvement 3
• Ensure adequate calcium and vitamin D supplementation given prolonged glucocorticoid exposure 1