What are the recommended treatments for arthritis?

Arthritis Treatment Recommendations

For osteoarthritis, begin with exercise, education, and weight loss (if overweight), then add topical NSAIDs for knee/hand involvement or oral NSAIDs at the lowest effective dose for the shortest duration, reserving acetaminophen as a second-line option due to inferior efficacy. 1, 2

Core Non-Pharmacologic Interventions (Start Here for All Patients)

• Exercise programs are strongly recommended for all patients with osteoarthritis of the hand, hip, and knee, including walking, strengthening exercises, neuromuscular training, and aquatic exercise 1, 2
• Weight loss is strongly recommended for patients with knee and/or hip OA who are overweight or obese as part of comprehensive management 1, 2
• Patient education and self-management programs should include information about the disease, coping strategies, activity pacing, and countering misconceptions that OA is inevitably progressive 1, 2

These interventions form the foundation of treatment and should be implemented before or alongside pharmacologic therapy. The evidence consistently shows these approaches improve both pain and function. 1

Joint-Specific Orthotic Interventions

• First carpometacarpal (CMC) joint orthoses are strongly recommended for hand arthritis, with conditional recommendations for orthoses at other hand joints 2
• Tibiofemoral bracing is strongly recommended for tibiofemoral OA, and patellofemoral bracing conditionally recommended for patellofemoral OA 2
• Cane use is strongly recommended to improve mobility in patients with knee and hip OA 2

Pharmacologic Treatment Algorithm

First-Line: Topical NSAIDs (for accessible joints)

• Topical NSAIDs are strongly recommended as first-line pharmacologic therapy for knee OA and hand OA before considering oral medications 1, 2
• This approach minimizes systemic exposure and associated cardiovascular, renal, and gastrointestinal risks 1

Second-Line: Oral NSAIDs (when topical therapy insufficient)

• Oral NSAIDs are strongly recommended for hand, knee, and hip OA when topical therapy is inadequate 1, 2
• Use the lowest effective dose for the shortest possible duration after evaluating gastrointestinal, renal, and cardiovascular risks 1
• Prescribe with a proton pump inhibitor to reduce GI complications, selecting the one with lowest acquisition cost 1
• Choose either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID as first choice 1

Critical evidence point: NSAIDs are more effective than acetaminophen for OA pain relief. Recent comparative studies demonstrate superior efficacy of NSAIDs over acetaminophen, with acetaminophen showing only a 5% relative improvement from baseline (4 points on 0-100 scale) compared to placebo—a benefit of questionable clinical significance. 3 This contradicts older recommendations that prioritized acetaminophen first-line.

Third-Line: Alternative Analgesics

• Acetaminophen (up to 4000 mg/day), duloxetine, or tramadol are conditionally recommended as second-line options when NSAIDs are contraindicated or ineffective 2, 4
• Regular dosing of acetaminophen may be needed rather than as-needed use 1

Adjunctive: Topical Capsaicin

• Consider topical capsaicin for additional pain relief, particularly for knee and hand OA 1

Intra-Articular Glucocorticoid Injections

• Intra-articular glucocorticoid injections should be considered for relief of local symptoms of inflammation 1
• These provide targeted relief without systemic side effects and can be particularly useful for oligoarticular involvement 5

Systemic Glucocorticoids (Use Cautiously)

• Systemic glucocorticoids reduce pain and swelling but should be used at the lowest dose necessary as temporary adjunctive treatment for less than 6 months due to cumulative side effects 1
• This is appropriate only for short-term bridging therapy, not chronic management 1

Additional Therapeutic Modalities (Conditional Recommendations)

• Mind-body interventions including yoga, cognitive behavioral therapy, and acupuncture are conditionally recommended 2
• Physical modalities such as thermal applications (heat or cold), massage therapy, balance exercises, transcutaneous electrical nerve stimulation (TENS), and radiofrequency ablation are conditionally recommended 1, 2
• Manipulation and stretching particularly for hip OA 1

What NOT to Use

• Glucosamine and chondroitin products are not recommended due to insufficient evidence of benefit 1
• Electroacupuncture should not be used 1

Monitoring and Adjustment

• Regular periodic review tailored to individual needs should assess the effect on function, quality of life, occupation, mood, relationships, and leisure activities 1
• Formulate management plans in partnership with the patient, considering comorbidities that compound OA effects 1
• Adjust the treatment plan regularly based on patient response, disease progression, and development of comorbidities 2

Common Pitfalls to Avoid

• Failing to implement core non-pharmacologic interventions (exercise, education, weight loss) before or alongside medications reduces treatment effectiveness 1, 2
• Using acetaminophen as first-line therapy when NSAIDs would be more effective—recent evidence shows NSAIDs provide superior pain relief for moderate-to-severe OA pain 3
• Prescribing oral NSAIDs without gastroprotection in at-risk patients increases adverse GI events from 13% to 19% 3
• Continuing NSAIDs long-term without reassessment increases cardiovascular, renal, and GI risks unnecessarily 1
• Not considering assistive devices (walking sticks, tap turners) for patients with specific functional limitations 1

Special Consideration: Inflammatory Arthritis

If inflammatory arthritis (rheumatoid arthritis, early arthritis) is suspected rather than osteoarthritis:

• Refer to rheumatology within 6 weeks of symptom onset 6
• Start methotrexate 10-15 mg/week (increasing to 15-25 mg/week) for patients at risk of persistent disease, ideally within 3 months of symptom onset 1, 6
• Add short-term systemic glucocorticoids (less than 6 months) as bridge therapy while awaiting DMARD effect 1, 6
• Monitor disease activity every 1-3 months using tender/swollen joint counts, ESR, CRP, and composite measures targeting remission 1, 6