What are the recommended management and treatment options for osteoarthritis?

Management and Treatment of Osteoarthritis

Begin with exercise therapy and weight loss (if overweight/obese) as the foundation, add topical NSAIDs for localized pain, escalate to oral NSAIDs with gastroprotection for inadequate relief, and reserve intra-articular corticosteroid injections for acute flares. 1, 2

Non-Pharmacological Interventions (Mandatory First-Line)

Exercise Therapy (Strongest Recommendation)

• Land-based exercise combining aerobic fitness and local muscle strengthening is strongly recommended for all patients with hip, knee, or hand OA. 1, 2
• Tai chi receives a strong recommendation specifically for knee OA and provides both pain relief and functional improvement. 1
• Aquatic exercise can be used as an alternative for patients who cannot tolerate land-based exercise. 3
• Balance exercises and yoga receive conditional recommendations as adjuncts. 1

Weight Management (Critical for Overweight/Obese Patients)

• Weight loss is strongly recommended for patients with knee and/or hip OA who have BMI ≥25 kg/m², as even modest weight reduction significantly reduces mechanical stress on weight-bearing joints. 1, 2, 4
• This intervention directly impacts disease progression, not just symptoms. 4

Patient Education and Self-Management

• Self-efficacy and self-management programs receive strong recommendations and must counter the misconception that OA is inevitably progressive and untreatable. 1, 5
• Provide both oral and written information about activity modification and joint protection techniques. 5, 4

Assistive Devices and Orthoses

• Cane use receives a strong recommendation for hip and knee OA to reduce joint loading during ambulation. 1, 2
• Hand orthoses for first carpometacarpal (CMC) joint OA receive a strong recommendation. 1
• Tibiofemoral bracing receives a strong recommendation specifically for tibiofemoral knee OA. 1
• Patellofemoral bracing receives a conditional recommendation for patellofemoral knee OA. 1
• Appropriate footwear with shock-absorbing properties should be recommended. 5

Pharmacological Treatment Algorithm

Step 1: Topical Therapy (First-Line Pharmacological)

• Topical NSAIDs receive a strong recommendation for knee OA and should be used before oral NSAIDs due to fewer systemic side effects. 1, 2
• Topical NSAIDs also receive conditional recommendations for hand OA. 1
• Topical capsaicin receives a conditional recommendation for knee OA as an alternative or adjunct. 1, 4

Step 2: Oral Analgesics

• Acetaminophen (paracetamol) can be used at regular dosing up to 4,000 mg/day, but has limited efficacy compared to NSAIDs and requires monitoring for hepatotoxicity. 2, 5, 4
• This receives only a conditional recommendation due to modest efficacy. 1

Step 3: Oral NSAIDs (When Topical Insufficient)

• Oral NSAIDs receive a strong recommendation for knee OA but must be prescribed at the lowest effective dose for the shortest duration. 1, 2
• Mandatory risk assessment before prescribing: evaluate cardiovascular, gastrointestinal, and renal risk factors, especially in elderly patients. 2, 5
• Co-prescribe proton pump inhibitor for gastroprotection, particularly in elderly patients. 5
• All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but vary significantly in toxicity profiles. 5, 6
• Naproxen causes statistically significantly less gastric bleeding and erosion than aspirin (1000 mg naproxen vs 3250 mg aspirin in blood loss studies). 6

Step 4: Alternative Systemic Agents

• Duloxetine receives a conditional recommendation for patients with inadequate response to NSAIDs. 1, 4
• Tramadol receives a conditional recommendation for short-term management of severe pain, but use with extreme caution due to dependence risk. 1, 4

Step 5: Intra-Articular Injections

• Intra-articular glucocorticoid injections receive a strong recommendation for knee OA and provide short-term relief (4-8 weeks) for acute flares. 1, 2, 7
• Intra-articular corticosteroid injections receive conditional recommendations for hand OA. 1
• Hyaluronic acid injections are more expensive but can maintain symptom improvement for longer periods than corticosteroids. 7

Step 6: Advanced Interventions

• Radiofrequency ablation receives a conditional recommendation for knee OA when other measures fail. 1
• Cognitive behavioral therapy receives a conditional recommendation as an adjunct for pain management. 1
• Acupuncture receives a conditional recommendation. 1

What NOT to Use (Common Pitfalls)

• Glucosamine and chondroitin supplements are NOT recommended, as they have not shown significant benefits over placebo. 2, 5
• Chondroitin sulfate receives only a conditional recommendation for hand OA specifically, but not for knee or hip. 1
• Electroacupuncture is NOT recommended based on current evidence. 2, 5
• Avoid combining NSAIDs with aspirin, as aspirin increases naproxen excretion rates and the combination results in higher adverse event frequency without demonstrated superior efficacy. 6
• Do not use opioids for long-term pain management. 4

Surgical Referral Criteria

• Refer for total joint replacement assessment when patients have severe symptomatic OA with chronic pain and disability despite maximal conservative therapy. 2, 7
• Do not delay surgical referral when conservative measures consistently fail. 4

Monitoring Requirements

• Provide periodic review tailored to individual needs, as disease course and patient requirements change over time. 5, 8
• Assess treatment effectiveness regularly and adjust accordingly. 5, 4
• Monitor for NSAID-related hepatotoxicity, particularly with acetaminophen at maximum doses. 2
• Monitor cardiovascular, gastrointestinal, and renal function in patients on chronic NSAID therapy. 2, 5

Critical Safety Considerations

• Elderly patients have increased baseline cardiovascular risk and require especially careful assessment before NSAID prescription. 5
• Avoid overreliance on passive treatments without active exercise therapy. 4
• Do not fail to address biomechanical factors such as weight and knee alignment. 4
• Thermal modalities (heat/cold) and TENS receive conditional recommendations for temporary pain relief only. 1, 2