What are the treatment options for osteoarthritis?

Osteoarthritis Treatment

All patients with osteoarthritis should receive three core treatments first—patient education, exercise therapy (including local muscle strengthening and general aerobic fitness), and weight loss if overweight or obese—before considering any pharmacological interventions. 1

Core Treatments (Mandatory First-Line for All Patients)

These three interventions form the foundation and must be offered to every patient with symptomatic osteoarthritis:

• Patient education with both oral and written information to counter the misconception that osteoarthritis is inevitably progressive and untreatable 1, 2
• Exercise therapy including local muscle strengthening and general aerobic fitness training, which improves both pain and function regardless of age, structural disease severity, or pain levels 1, 2, 3
• Weight loss interventions if the patient is overweight or obese, as this reduces mechanical stress on weight-bearing joints 1, 2, 4

Pharmacological Treatment Algorithm

First-Line Pharmacological Options (After Core Treatments)

• Paracetamol (acetaminophen) at regular dosing up to 4,000 mg/day for pain relief 1, 2, 4
• Topical NSAIDs should be considered before oral NSAIDs, particularly for knee and hand osteoarthritis, as they provide similar efficacy with fewer systemic side effects 1, 2, 4

Second-Line Pharmacological Options

If paracetamol and topical NSAIDs provide insufficient pain relief:

• Oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period 1, 4
• Mandatory co-prescription of a proton pump inhibitor when using oral NSAIDs, especially in elderly patients 4
• Risk assessment is essential before prescribing oral NSAIDs: evaluate cardiovascular risk factors (especially in elderly), gastrointestinal risk factors (history of ulcers, concurrent corticosteroid or anticoagulant use), and renal function 1, 4, 5

Critical caveat: All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but vary significantly in gastrointestinal, liver, and cardiorenal toxicity. 1 The FDA warns that NSAIDs can cause ulcers and bleeding in the stomach and intestines at any time during treatment, which can happen without warning and may cause death. 5 The risk increases with longer use, smoking, alcohol consumption, older age, and concurrent use of corticosteroids or anticoagulants. 5

Third-Line Pharmacological Options

• Opioid analgesics if previous treatments are insufficient 1, 6
• Intra-articular corticosteroid injections for moderate to severe pain 1, 2, 6

Adjunct Non-Pharmacological Treatments

After establishing core treatments, consider these additional modalities:

• Self-management strategies emphasizing exercise, weight loss, appropriate footwear with shock-absorbing properties, and activity pacing to avoid overexertion 1, 2, 4
• Local heat or cold applications for temporary pain relief 1, 2, 6
• Manual therapy (manipulation and stretching), particularly for hip osteoarthritis 1, 2, 6
• Transcutaneous electrical nerve stimulation (TENS) for pain management 1, 2
• Bracing, joint supports, or insoles for patients with biomechanical joint pain or instability 1, 2, 6
• Assistive devices (walking sticks, tap turners) for those with specific problems with activities of daily living 1, 2, 6

What NOT to Use

Do not recommend the following treatments, as they lack evidence of benefit:

• Glucosamine and chondroitin products are not recommended 1, 2, 4, 6
• Electroacupuncture should not be used 1, 4
• Rubefacients and intra-articular hyaluronan injections are not recommended 1

Surgical Referral Criteria

Refer for joint replacement surgery when:

• Joint symptoms (pain, stiffness, reduced function) substantially affect quality of life AND are refractory to non-surgical treatment 1
• Referral should occur before there is prolonged and established functional limitation and severe pain 1
• Patient-specific factors (age, sex, smoking, obesity, comorbidities) should NOT be barriers to referral 1

Do not refer for arthroscopic lavage and debridement unless the patient has knee osteoarthritis with a clear history of mechanical locking (not for gelling, "giving way," or x-ray evidence of loose bodies) 1

Monitoring and Follow-Up

• Provide periodic review tailored to individual needs, as disease course and patient requirements change over time 1, 4, 6
• Assess treatment effectiveness regularly and adjust accordingly 2, 4
• Holistic assessment should include the effect on function, quality of life, occupation, mood, relationships, and leisure activities 1

Common Pitfalls to Avoid

• Do not skip core treatments: Many clinicians jump directly to pharmacological interventions without establishing the foundation of education, exercise, and weight management 1, 2
• Do not prescribe NSAIDs without risk assessment: Elderly patients and those with cardiovascular, gastrointestinal, or renal risk factors require careful evaluation before NSAID prescription 1, 4, 5
• Do not delay surgical referral excessively: Refer before prolonged functional limitation becomes established 1
• Do not use aspirin with NSAIDs: Aspirin increases the rate of excretion of naproxen, and the combination may result in higher frequency of adverse events 5