What is the recommended treatment for an adult patient with osteoarthritis?

Treatment for Osteoarthritis in Adults

All adults with symptomatic osteoarthritis must receive three core non-pharmacological treatments—patient education, exercise (muscle strengthening and aerobic fitness), and weight loss if overweight—as these form the foundation of management, with pharmacological treatments serving only as adjuncts. 1

Core Non-Pharmacological Treatments (Essential for All Patients)

These are not optional—every patient with osteoarthritis requires these interventions regardless of pharmacological therapy:

• Patient education with both oral and written information to counter the harmful misconception that osteoarthritis is inevitably progressive and untreatable 1
• Exercise programs including local muscle strengthening exercises and general aerobic fitness training 1, 2
• Weight loss interventions if the patient is overweight or obese, as this directly reduces mechanical joint stress 1, 2

Pharmacological Treatment Algorithm

First-Line: Acetaminophen (Paracetamol)

• Start with acetaminophen at regular doses up to 4000 mg daily as the safest initial pharmacologic option 1, 3, 2
• Use regular scheduled dosing rather than "as needed" for better sustained pain control in chronic osteoarthritis 1, 3
• Consider staying at or below 3000 mg daily in elderly patients for enhanced safety 3
• Acetaminophen provides modest pain relief with the best safety profile compared to all other pharmacological options 3, 4

Important caveat: While acetaminophen is recommended first-line by guidelines 1, research evidence shows it is less effective than NSAIDs for moderate-to-severe pain, with only a 5% relative improvement and questionable clinical significance 4. The guideline recommendation prioritizes safety over efficacy.

Second-Line: Topical NSAIDs

• Apply topical NSAIDs (such as diclofenac gel) before considering oral NSAIDs, particularly for knee and hand osteoarthritis 1, 3, 2
• Topical NSAIDs have minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications compared to oral formulations 3
• Topical capsaicin is an alternative localized agent that may provide pain relief 1

Third-Line: Oral NSAIDs or COX-2 Inhibitors

Only prescribe when acetaminophen and topical NSAIDs have failed:

• Use at the lowest effective dose for the shortest possible duration 1, 3, 2
• Always co-prescribe a proton pump inhibitor alongside any oral NSAID or COX-2 inhibitor for gastroprotection, choosing the one with lowest acquisition cost 1, 3, 2
• First choice should be either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID 1
• All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but vary significantly in gastrointestinal, liver, and cardiorenal toxicity 1, 2

Fourth-Line: Opioid Analgesics

• Consider adding opioid analgesics if paracetamol and NSAIDs are insufficient 1
• Opioids and NSAIDs are mutually dose-sparing and can be combined at relatively low doses for synergistic analgesia while limiting toxicity 5

Intra-Articular Corticosteroid Injections

• Consider for moderate to severe pain, especially with joint effusion 1, 6
• Provides short-term pain relief particularly useful during disease flares 7, 6

Critical Safety Considerations

Before Prescribing Oral NSAIDs:

• Carefully assess cardiovascular, gastrointestinal, and renal risk factors, particularly in patients over 50 years 3, 2
• Elderly patients face substantially higher risks of GI bleeding, renal insufficiency, and cardiovascular complications with NSAIDs 3, 2
• NSAIDs should never be used right before or after coronary artery bypass graft (CABG) surgery 8
• Risk of ulcers and bleeding increases with longer use, smoking, alcohol consumption, older age, poor health, and concurrent use of corticosteroids or anticoagulants 8

If Patient Takes Low-Dose Aspirin:

• Consider other analgesics before adding an NSAID or COX-2 inhibitor (plus proton pump inhibitor) 1
• Combination of aspirin with NSAIDs increases gastrointestinal bleeding risk 1

Adjunct Non-Pharmacological Treatments

• Self-management strategies emphasizing exercise, weight loss, appropriate footwear with shock-absorbing properties, and activity pacing to avoid peaks and troughs 1, 2
• Local heat or cold applications for temporary symptomatic relief 1, 2
• Manipulation and stretching, particularly for hip osteoarthritis 1
• Transcutaneous electrical nerve stimulation (TENS) 1
• Bracing, joint supports, or insoles for those with biomechanical joint pain or instability 1
• Assistive devices (walking sticks, tap turners) for those with specific problems in activities of daily living 1

What NOT to Use

• Do not recommend glucosamine or chondroitin products—current evidence does not support their efficacy 1, 2
• Do not use electroacupuncture 1, 2
• Insufficient evidence exists to make a firm recommendation on acupuncture 1
• Avoid combination of NSAIDs with aspirin—aspirin increases the rate of excretion of NSAIDs, and the combination results in higher frequency of adverse events without demonstrated superior efficacy 8

Common Pitfalls to Avoid

• Never exceed 4000 mg daily of acetaminophen, and strongly consider lower limits (3000 mg) in elderly patients to prevent hepatotoxicity 3
• Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor co-prescription) 1, 3, 2
• Avoid prolonged NSAID use at high doses, particularly in elderly patients who are at highest risk for serious adverse events including GI bleeding, renal failure, and cardiovascular complications 3, 2, 8
• Do not rely solely on pharmacological treatment—the core non-pharmacological interventions (education, exercise, weight loss) are essential and must not be omitted 1, 2

Monitoring and Follow-Up

• Provide periodic review tailored to individual needs, as disease course and patient requirements change over time 1, 2, 9
• Assess the effect of osteoarthritis on function, quality of life, occupation, mood, relationships, and leisure activities 1
• Formulate management plans in partnership with the patient, taking into consideration comorbidities that compound the effect of osteoarthritis 1