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 for hip/knee/hand arthritis, reserving surgery for disabling disease that fails conservative management. 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 osteoarthritis 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 osteoarthritis is inevitably progressive and untreatable 1, 2

These three interventions form the foundation of treatment and should be implemented before or alongside pharmacologic therapy. 1

Joint-Specific Orthotic Interventions

• For hand osteoarthritis: First carpometacarpal (CMC) joint orthoses are strongly recommended, with conditional recommendation for orthoses at other hand joints 1, 2
• For knee osteoarthritis: Tibiofemoral bracing is strongly recommended for tibiofemoral involvement, with conditional recommendation for patellofemoral bracing 2
• Cane use is strongly recommended to improve mobility in patients with knee and hip osteoarthritis 2

Pharmacologic Treatment Algorithm

First-Line Pharmacologic Options

For knee and hand osteoarthritis:

• Start with topical NSAIDs (strongly recommended) before progressing to oral agents 1, 2
• Paracetamol (acetaminophen) can be offered for pain relief at regular dosing up to 4000 mg/day, though evidence shows it provides only modest benefit with a 5% relative improvement and absolute change of 4 points on a 0-100 scale 1, 3

For hip, knee, and hand osteoarthritis:

• Oral NSAIDs are strongly recommended when topical agents or acetaminophen are insufficient 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 (choose the lowest acquisition cost option) to reduce GI complications 1

Second-Line Options

• Acetaminophen, duloxetine, and tramadol are conditionally recommended as second-line options when NSAIDs are contraindicated or insufficient 2
• Note that NSAIDs demonstrate superior efficacy compared to acetaminophen, particularly in patients with moderate-to-severe pain, though the treatment effect is modest 3, 4

Glucocorticoid Injections

• Intra-articular glucocorticoid injections should be considered for relief of local inflammatory symptoms 1, 5
• Systemic glucocorticoids may reduce pain and swelling but should be used at the lowest dose for the shortest duration (less than 6 months) due to cumulative side effects 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, and radiofrequency ablation are conditionally recommended 1, 2
• TENS (transcutaneous electrical nerve stimulation) may be considered 1
• Manipulation and stretching particularly for hip osteoarthritis 1

What NOT to Use

• Glucosamine and chondroitin products are not recommended 1
• Electroacupuncture should not be used 1

Special Considerations for 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 as tolerated) for patients at risk of persistent disease, ideally within 3 months of symptom onset 1, 6, 7
• Methotrexate is the anchor drug and should be part of first treatment strategy unless contraindicated 1
• Monitor disease activity every 1-3 months using tender/swollen joint counts, ESR, CRP, and composite measures 1, 6

Surgical Intervention

• Surgery is recommended for disabling osteoarthritis that has not improved with nonsurgical care 1

Common Pitfalls to Avoid

• Failing to implement core non-pharmacologic interventions (exercise, education, weight loss) before or alongside medications—these are not optional 1, 2
• Using oral NSAIDs before trying topical NSAIDs for knee and hand osteoarthritis 1, 2
• Prescribing NSAIDs without assessing GI, renal, and cardiovascular risks and without gastroprotection 1
• Using NSAIDs at higher than necessary doses or for longer than needed—always use minimum effective dose for shortest duration 1
• Relying solely on acetaminophen for moderate-to-severe pain—NSAIDs are more effective in this population 3, 4
• Prescribing glucosamine/chondroitin despite lack of evidence supporting their use 1