What is the treatment for severe osteoarthritis?

Treatment for Severe Osteoarthritis

For severe osteoarthritis with symptoms substantially affecting quality of life that are refractory to conservative treatment, refer for joint replacement surgery before prolonged functional limitation develops, while ensuring core treatments (exercise, weight loss if overweight, and NSAIDs or intra-articular corticosteroids) have been attempted first. 1

Surgical Intervention for Severe Disease

Joint replacement surgery is the definitive treatment for severe osteoarthritis when conservative measures fail. 1

• Refer patients for joint replacement when joint symptoms (pain, stiffness, reduced function) substantially affect quality of life and remain refractory to non-surgical treatment 1
• Make referrals before prolonged and established functional limitation and severe pain develop—early referral improves outcomes 1
• Patient-specific factors including age, sex, smoking, obesity, and comorbidities should not be barriers to surgical referral 1
• Do not routinely offer arthroscopic lavage and debridement for osteoarthritis treatment, unless knee osteoarthritis presents with clear mechanical locking (not for "gelling," "giving way," or radiographic loose bodies) 1

Core Treatments Required Before Surgical Referral

Before considering surgery, ensure patients have received these evidence-based core interventions 1, 2:

Non-Pharmacological Core Treatments (Must Be Offered First)

• Weight loss if overweight or obese—reduces mechanical stress on weight-bearing joints and significantly improves pain 1, 2
• Strengthening exercise and aerobic fitness training—land-based and aquatic exercises improve pain and function 1, 2
• Patient education—essential to counter misconceptions about osteoarthritis and improve treatment adherence 1, 2

Pharmacological Treatments for Severe Pain

Step 1: First-line analgesics

• Paracetamol (acetaminophen) up to 4,000 mg/day in divided doses—safest first-line option 1, 2
• Topical NSAIDs—particularly effective for knee and hand osteoarthritis with fewer systemic side effects than oral NSAIDs 1, 2

Step 2: Oral NSAIDs or COX-2 inhibitors (if first-line insufficient)

• Use the lowest effective dose for the shortest duration 1
• All oral NSAIDs and COX-2 inhibitors have similar analgesic magnitude but vary in gastrointestinal, liver, and cardiorenal toxicity 1
• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing, especially in elderly patients 1, 2
• Add a proton pump inhibitor for gastroprotection when using oral NSAIDs 1
• Naproxen causes statistically significantly less gastric bleeding than aspirin in comparative studies 3

Step 3: Intra-articular corticosteroid injections

• Consider for moderate to severe pain when oral medications provide insufficient relief 1
• Particularly effective for acute pain flares 1

Step 4: Opioids (reserved for refractory cases)

• Consider only when NSAIDs and intra-articular injections are insufficient or contraindicated 1
• Use cautiously given addiction potential and side effect profile 1

Adjunctive Treatments for Symptom Management

These provide additional benefit but are less effective than core treatments 1:

• Capsaicin cream—topical application for localized pain relief 1
• Local heat and cold applications—temporary pain relief 1, 2
• Transcutaneous electrical nerve stimulation (TENS)—for pain management 1, 2
• Manual therapy (manipulation and stretching)—may provide temporary benefit 1
• Assistive devices (canes, walkers, braces)—reduce joint load and improve function 1, 2
• Shock-absorbing shoes or insoles—reduce impact on weight-bearing joints 1

Critical Pitfalls to Avoid

• Do NOT delay surgical referral until severe functional limitation is established—refer earlier rather than later 1
• Do NOT use rubefacients or intra-articular hyaluronan injections—not recommended for osteoarthritis treatment 1
• Do NOT use glucosamine or chondroitin supplements—no significant benefits over placebo 2
• Do NOT combine NSAIDs with aspirin—aspirin increases NSAID excretion and raises adverse event frequency without additional benefit 3
• Do NOT prescribe oral NSAIDs without assessing individual risk factors for gastrointestinal bleeding, cardiovascular events, and renal dysfunction 1

Treatment Algorithm for Severe Osteoarthritis

1. Confirm core treatments attempted: exercise, weight loss (if applicable), paracetamol, topical NSAIDs 1, 2
2. If inadequate response: Add oral NSAIDs with gastroprotection (assess risk factors first) 1
3. If still inadequate: Add intra-articular corticosteroid injections for moderate-severe pain 1
4. If symptoms substantially affect quality of life despite above: Refer for joint replacement surgery evaluation 1
5. Continue non-pharmacological treatments throughout to optimize outcomes 1