What are the treatment options for osteoarthritis?

Osteoarthritis Treatment

Start every patient with the core triad of exercise, weight loss (if overweight/obese), and patient education—these are non-negotiable first-line interventions that must be implemented before or alongside any pharmacological therapy. 1, 2, 3

Core Treatments (Mandatory for All Patients)

Non-Pharmacological Foundation

• Exercise programs including strengthening exercises (targeting local muscle groups around affected joints), aerobic fitness training (at least 30 minutes most days), and aquatic exercise for those unable to tolerate land-based activities 1, 2, 3
• Weight loss is mandatory for overweight or obese patients—even 5-10% body weight reduction significantly reduces joint pain and mechanical stress on weight-bearing joints 2, 3, 4
• Patient education to counter the misconception that osteoarthritis is inevitably progressive and untreatable, emphasizing self-management strategies and behavioral modifications 1, 2

Pharmacological Treatment Algorithm

Step 1: First-Line Analgesics

• Paracetamol (acetaminophen) up to 4,000 mg/day in divided doses for mild to moderate pain, though recent evidence shows limited efficacy 1, 2, 3
• Topical NSAIDs are strongly preferred for knee and hand osteoarthritis before oral NSAIDs due to effective pain relief with minimal systemic exposure 1, 2, 3
• Topical capsaicin can be considered as an adjunct for localized pain 1

Step 2: Oral NSAIDs (When Topical Therapy Insufficient)

• Use oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest duration 1, 2
• Always prescribe with a proton pump inhibitor (choose the lowest acquisition cost option) for gastroprotection 1
• Mandatory risk assessment before initiating: evaluate cardiovascular risk, gastrointestinal history, renal function, age, and concomitant aspirin use 1, 2
• For patients on low-dose aspirin, exhaust other analgesic options before adding NSAIDs due to compounded gastrointestinal risk 1
• Naproxen has been shown to cause statistically significantly less gastric bleeding than aspirin in controlled studies 5

Step 3: Additional Pharmacological Options

• Opioid analgesics (such as tramadol) only when paracetamol and topical NSAIDs are insufficient—add to or substitute for first-line agents, but reserve for refractory cases due to dependence risk 1, 2, 3
• Duloxetine is conditionally recommended for patients with inadequate response to first-line treatments or comorbid depression 3

Step 4: Intra-Articular Injections

• Corticosteroid injections for moderate to severe pain, particularly effective during acute flares—provide short-term relief for knee, hip, and shoulder osteoarthritis 1, 2, 3, 4
• Consider for patients with persistent symptoms despite oral therapy 3, 4

Adjunctive Non-Pharmacological Treatments

Physical Modalities

• Local heat or cold applications for temporary symptomatic relief 1, 2, 3
• Manual therapy (manipulation and stretching), particularly beneficial for hip osteoarthritis 1, 3
• Transcutaneous electrical nerve stimulation (TENS) for pain management 1, 2, 3

Biomechanical Interventions

• Shock-absorbing shoes or insoles to reduce joint impact 1
• Bracing and supports: tibiofemoral bracing for tibiofemoral OA (strongly recommended), patellofemoral bracing for patellofemoral OA, and first carpometacarpal joint orthoses for hand OA 3
• Assistive devices (walking sticks, canes, tap turners) for patients with functional limitations—canes are strongly recommended for hip OA 1, 3

Behavioral Modifications

• Pacing activities to avoid peaks and troughs of joint stress 1, 2
• Appropriate footwear with shock-absorbing properties 1, 4

Treatments NOT Recommended

• Glucosamine and chondroitin products are not recommended—insufficient evidence of benefit over placebo 1, 2, 3
• Intra-articular hyaluronan injections are not recommended for routine use 1
• Electroacupuncture should not be used 1, 3
• Rubefacients are not recommended 1

Surgical Referral Criteria

When to Refer for Joint Replacement

• Refer when joint symptoms (pain, stiffness, reduced function) substantially affect quality of life and are refractory to comprehensive non-surgical treatment 1
• Refer before prolonged and established functional limitation develops—do not wait until severe disability occurs 1
• Patient-specific factors (age, sex, smoking, obesity, comorbidities) should NOT be barriers to referral 1
• Ensure the patient has been offered at least the core treatment options (exercise, weight loss, education) plus appropriate pharmacological trials before surgical consideration 1

Arthroscopic Procedures

• Do NOT routinely refer for arthroscopic lavage and debridement unless the patient has knee osteoarthritis with a clear history of mechanical locking 1
• Common inappropriate reasons for arthroscopic referral include gelling, "giving way," or x-ray evidence of loose bodies without mechanical symptoms 1

Monitoring and Follow-Up

• Periodic review tailored to individual needs as disease course and requirements change over time 1, 2
• Monitor renal and hepatic function when using NSAIDs, particularly in elderly patients and those with comorbidities 1, 2, 4
• Reassess at 6-12 weeks to determine if escalation of therapy is needed 4
• Regular assessment of treatment effectiveness and adjustment of the management plan in partnership with the patient 1, 2

Critical Pitfalls to Avoid

• Do not combine NSAIDs with aspirin without gastroprotection—this significantly increases gastrointestinal bleeding risk 1
• Do not use NSAIDs and aspirin together routinely—the combination may result in higher frequency of adverse events than either alone 5
• Do not delay surgical referral until severe disability is established—refer when quality of life is substantially affected despite conservative treatment 1
• Do not underutilize core non-pharmacological treatments—exercise and weight management are frequently neglected but are essential components of effective OA management 6
• Avoid overreliance on opioid analgesics—these should be reserved for refractory cases after exhausting safer alternatives 2, 3, 6