Treatment of Osteoarthritis (Arthrosis)
Begin with exercise therapy and weight loss (if overweight/obese) as the foundation, add topical NSAIDs for knee/hand involvement, escalate to oral NSAIDs with gastroprotection if needed, and reserve intra-articular corticosteroid injections for joints with effusion. 1, 2
First-Line Core Treatments (Start Here for All Patients)
Non-Pharmacological Foundation
Exercise therapy is mandatory and should include both land-based and aquatic exercises focusing on local muscle strengthening and general aerobic fitness. 1, 2 This improves pain and function more effectively than many pharmacological interventions.
Weight loss is essential for overweight or obese patients to reduce mechanical stress on weight-bearing joints—this directly impacts disease progression and symptom severity. 1, 2, 3
Patient education must counter the misconception that osteoarthritis is inevitably progressive—emphasize that appropriate treatment can significantly improve outcomes and that the condition is manageable. 1, 2, 3
Pharmacological First-Line
Start with topical NSAIDs for knee and hand osteoarthritis—these provide comparable pain relief to oral NSAIDs with significantly fewer systemic side effects. 1, 2
Acetaminophen (paracetamol) can be tried as an alternative first-line option with regular dosing up to 4,000 mg/day, though it is generally less effective than NSAIDs for moderate pain. 1, 2, 3 Monitor for hepatotoxicity with prolonged use.
Second-Line Pharmacological Treatment
When to Escalate
- If topical NSAIDs and acetaminophen provide insufficient pain relief, escalate to oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest duration. 2, 3
Risk Assessment Before Oral NSAIDs
Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing oral NSAIDs, particularly in patients over 50 years old. 1, 2, 3 Naproxen has been shown to cause statistically significantly less gastric bleeding and erosion than aspirin in controlled studies. 4
Always add a proton pump inhibitor for gastroprotection when prescribing oral NSAIDs or COX-2 inhibitors. 2, 3
Common Adverse Effects to Monitor
- The most frequent adverse reactions with naproxen (occurring in 3-9% of patients) include heartburn, abdominal pain, nausea, headache, dizziness, drowsiness, pruritus, skin eruptions, and edema. 4 Gastrointestinal reactions are more frequent and severe at higher doses (1500 mg/day vs 750 mg/day). 4
Adjunctive Non-Pharmacological Treatments
Local heat or cold applications provide temporary pain relief and can be used as needed for symptom management. 1, 2, 3
Transcutaneous electrical nerve stimulation (TENS) and manual therapy may provide additional pain relief when combined with exercise. 1, 3
Assistive devices (walking aids, braces) should be prescribed to reduce joint load and improve functional ability in patients with mobility limitations. 1, 2, 3
Appropriate footwear with shock-absorbing properties reduces joint stress during daily activities. 2
Specific Treatment for Joint Effusion
- Intra-articular corticosteroid injection is specifically indicated for knee pain with effusion—this provides targeted anti-inflammatory effect when systemic treatments are insufficient. 2
Third-Line Options (For Refractory Cases)
- Opioid analgesics may be considered if previous treatments are insufficient, though this should be approached cautiously given the risks of dependence and adverse effects. 3
Treatments NOT Recommended
Do not prescribe glucosamine or chondroitin supplements—they have not shown significant benefits over placebo in high-quality trials. 1, 2, 3, 5
Electroacupuncture is not recommended based on current evidence. 1
Avoid combining naproxen with aspirin—aspirin increases the rate of naproxen excretion, and the combination results in higher frequency of adverse events without demonstrated superior efficacy. 4
Surgical Considerations
Joint replacement surgery should be considered only after conservative treatments have failed and when joint symptoms substantially impact quality of life despite optimal medical management. 1, 3
Arthroscopic procedures should generally be avoided—they have not shown benefit over sham procedures or optimized physical and medical therapy. 5
Monitoring and Follow-Up
- Regular monitoring and periodic review of treatment effectiveness are essential as disease course and patient needs change over time—do not rigidly continue a single treatment without reassessment. 1, 2, 3, 6
Common Pitfalls to Avoid
Do not rely solely on pharmacological treatment—the evidence strongly supports that exercise and weight management are foundational and cannot be replaced by medications alone. 1, 7
Do not prescribe oral NSAIDs without gastroprotection in at-risk patients—this significantly increases the risk of serious upper gastrointestinal adverse events. 2, 6
Do not use opioids as first-line therapy—there is significant overuse of opioid analgesics in osteoarthritis management when more appropriate options exist. 7