What are the recommended treatment options for a patient with osteoarthritis?

Osteoarthritis Treatment

Start with Core Treatments for Every Patient

All patients with osteoarthritis should receive three foundational interventions immediately: structured exercise (strengthening and aerobic), weight loss if overweight or obese, and patient education—these are non-negotiable first-line therapies before considering any medications. 1, 2

Exercise Therapy (Mandatory)

• Prescribe local muscle strengthening exercises targeting the affected joint, general aerobic fitness training (walking, cycling, swimming), and aquatic exercise programs 1, 2
• Aim for at least 30 minutes of exercise most days of the week 3
• Exercise provides pain relief and functional improvement comparable to many pharmacological agents 1, 2

Weight Loss (If BMI ≥25)

• Even 5-10% body weight reduction significantly reduces joint pain and mechanical stress on weight-bearing joints 3, 4
• This is a strong recommendation for knee and hip osteoarthritis 1, 2

Patient Education

• Provide written and oral information countering the misconception that osteoarthritis is inevitably progressive and untreatable 1, 2
• Teach joint protection techniques, pacing strategies (avoiding activity "peaks and troughs"), and self-management skills 1

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Pharmacological Treatment Algorithm

First-Line: Acetaminophen and Topical NSAIDs

Begin with acetaminophen (paracetamol) up to 4,000 mg/day in divided doses as the safest initial oral analgesic. 1, 2, 3

• For knee and hand osteoarthritis specifically, add or substitute topical NSAIDs applied 3-4 times daily to affected joints 1, 2, 3
• Topical NSAIDs have minimal systemic absorption, negligible bleeding risk, and fewer gastrointestinal side effects than oral NSAIDs 2, 3, 4
• Counsel patients to avoid all other acetaminophen-containing products to prevent hepatotoxicity 3

Second-Line: Oral NSAIDs (Use With Caution)

If acetaminophen and topical NSAIDs provide inadequate relief after 2-4 weeks, consider oral NSAIDs or COX-2 inhibitors 1:

• Use the lowest effective dose for the shortest duration 1, 3
• All oral NSAIDs have similar analgesic efficacy but vary in toxicity profiles 1, 5
• Mandatory risk assessment before prescribing: evaluate age (elderly at higher risk), cardiovascular disease history, renal function, gastrointestinal bleeding history, and concomitant antiplatelet/anticoagulant use 1, 6
• Co-prescribe a proton pump inhibitor for gastroprotection in patients with gastrointestinal risk factors 1, 3
• Critical contraindication: Avoid oral NSAIDs entirely in patients on antiplatelet therapy (e.g., ticagrelor, clopidogrel) due to significantly increased bleeding risk 4
• Naproxen causes statistically less gastric bleeding than aspirin and is comparable to other NSAIDs in efficacy 5

Third-Line: Intra-Articular Corticosteroid Injections

For moderate to severe pain flares unresponsive to oral medications 1, 3:

• Particularly effective for knee and hip osteoarthritis 3, 4
• Provides temporary relief (weeks to months) without systemic bleeding risk 4
• Safe option for patients on anticoagulation or antiplatelet therapy 4

Fourth-Line: Tramadol, Duloxetine, or Opioids

Only after inadequate response to the above therapies 1:

• Tramadol is conditionally recommended as an alternative analgesic 1
• Duloxetine (an SNRI) is conditionally recommended for patients with inadequate response to initial therapy 1
• Opioid analgesics are strongly recommended only for patients who refuse or have contraindications to joint replacement surgery after failing all other medical therapies 1

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Adjunctive Non-Pharmacological Treatments

Conditionally Recommended Modalities

• Thermal modalities: Local heat or cold applications for temporary pain relief 1, 2
• TENS (transcutaneous electrical nerve stimulation): May provide pain relief 1, 2
• Manual therapy: Manipulation and stretching, particularly for hip osteoarthritis 1, 2
• Assistive devices: Walking sticks, braces, joint supports, insoles for biomechanical instability, and adaptive equipment for activities of daily living 1, 2
• Appropriate footwear: Shoes with shock-absorbing properties 1, 2
• Tai chi and psychosocial interventions: Conditionally recommended for knee osteoarthritis 1

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Treatments NOT Recommended

Do not prescribe the following—they lack evidence of benefit: 1, 2, 3

• Glucosamine and chondroitin supplements 1, 2, 3
• Electroacupuncture 1, 2, 3
• Intra-articular hyaluronan injections (not routinely recommended) 1
• Rubefacients 1

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Surgical Referral Criteria

Refer for joint replacement surgery when: 1, 2, 3

• Pain and functional limitation substantially affect quality of life despite comprehensive conservative treatment for 3-6 months 2, 3, 4
• Symptoms are refractory to non-surgical treatment (core treatments plus pharmacological options) 1, 2
• Refer before prolonged and established functional limitation develops 1
• Patient-specific factors (age, sex, smoking, obesity, comorbidities) should not be barriers to referral 1

Do not refer for arthroscopic lavage and debridement unless there is a clear history of mechanical locking in knee osteoarthritis 1

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Critical Monitoring and Follow-Up

• Conduct periodic reviews tailored to individual needs, as disease course and requirements change over time 1, 2, 7
• Reassess treatment effectiveness, adherence, and emergence of new risk factors (cardiovascular, renal, gastrointestinal) at each visit 2, 6
• Monitor for hepatotoxicity with chronic acetaminophen use and gastrointestinal/cardiovascular/renal toxicity with NSAIDs 1, 3, 5