What are the treatment options for a patient with osteoarthritis?

Osteoarthritis Treatment

Start all patients with symptomatic osteoarthritis on a combination of self-management programs, strengthening exercises, low-impact aerobic activity, and neuromuscular education, while simultaneously initiating weight loss if BMI ≥25 kg/m², and use oral or topical NSAIDs (not acetaminophen alone) for pharmacologic pain control. 1, 2

Core Treatment Foundation (Mandatory for All Patients)

Non-pharmacological interventions form the foundation and must be implemented first:

• Exercise therapy is strongly recommended and includes land-based strengthening, low-impact aerobic exercise, and neuromuscular education 1, 2
• Weight loss should be pursued if BMI ≥25 kg/m², as this reduces mechanical stress on weight-bearing joints 1, 2
• Self-management programs with both oral and written patient education are essential to counter the misconception that osteoarthritis is inevitably progressive and untreatable 1, 2
• Aquatic exercise and Tai chi can be added as alternative exercise modalities 3

Pharmacological Treatment Algorithm

First-line pharmacologic options (choose based on patient factors):

• Topical NSAIDs should be considered first for knee and hand osteoarthritis, as they have fewer systemic side effects than oral agents 1
• Oral NSAIDs or COX-2 inhibitors are recommended as first-line treatment and are more effective than acetaminophen for moderate-to-severe pain 1
  • Use the lowest effective dose for the shortest duration 1
  • Mandatory co-prescription of proton pump inhibitor with all oral NSAIDs or COX-2 inhibitors 1, 4
  • Naproxen has been shown comparable to aspirin and indomethacin but with less frequent gastrointestinal and nervous system adverse effects 5

Second-line options if NSAIDs insufficient:

• Tramadol can be added or substituted if NSAIDs provide inadequate pain relief 1
• Topical capsaicin may be considered as an adjunct 1

Important caveat: While older guidelines mentioned acetaminophen/paracetamol as first-line, the AAOS guideline strongly recommends NSAIDs as the primary pharmacologic therapy, with acetaminophen having limited efficacy 1. The evidence shows NSAIDs are more effective for moderate-to-severe pain 6, 7.

Risk Assessment Before NSAID Use (Critical Safety Step)

Before prescribing any oral NSAID or COX-2 inhibitor, assess:

• Cardiovascular risk factors (especially in elderly patients who have increased baseline risk) 1, 4
• Gastrointestinal risk factors including history of ulcers or bleeding 1, 4
• Renal function as NSAIDs can cause renal toxicity 1, 5
• Age as elderly patients have higher risk of adverse events 4, 5

All oral NSAIDs have similar analgesic efficacy but vary significantly in gastrointestinal, hepatic, and cardiorenal toxicity profiles 1, 4.

Adjunct Non-Pharmacological Treatments

Consider adding these supportive interventions:

• Local heat or cold applications for temporary pain relief 1, 2
• TENS (transcutaneous electrical nerve stimulation) for pain management 1, 2
• Assistive devices including walking aids, braces, joint supports, or insoles for those with biomechanical joint pain or instability 1, 2
• Appropriate footwear with shock-absorbing properties 1, 4
• Activity pacing to avoid peaks and troughs of activity 1, 4
• Manipulation and stretching particularly for hip osteoarthritis 1

Injection Therapies

Corticosteroid injections:

• Evidence is inconclusive for routine use 1
• May be offered for short-term relief during acute flares or deterioration 8
• No established guidelines exist for administration frequency, and increased risk of tendon rupture and infection exists 9

Hyaluronic acid (viscosupplementation):

• Not recommended by AAOS guidelines despite some studies showing benefit 1

What NOT to Use (Common Pitfalls)

Avoid these interventions that lack evidence or are ineffective:

• Glucosamine and chondroitin are strongly not recommended—they show no significant benefit over placebo 1, 4, 7
• Acupuncture is not recommended based on lack of statistically significant evidence 1
• Electroacupuncture should not be used 1, 4
• Fish oil has not been found to reduce structural progression 7
• Arthroscopic procedures show no benefit over sham procedures or optimized medical therapy and should be avoided 7

Surgical Considerations

Joint replacement surgery should be considered for severe symptomatic osteoarthritis when conservative measures fail to provide adequate pain relief and functional improvement 2, 7, 8.

Monitoring and Follow-Up

Provide periodic review tailored to individual needs, as disease course and patient requirements change over time, requiring readjustment of therapy rather than rigid continuation of a single treatment 1, 4, 6.