What is the best treatment approach for a patient with osteoarthritis knee pain?

Treatment of Knee Osteoarthritis Pain

Start with acetaminophen up to 4,000 mg/day combined with exercise therapy and patient education, then escalate to topical or oral NSAIDs if inadequate response within 2 weeks. 1, 2

First-Line Treatment (Start Immediately)

Non-Pharmacological Interventions (Mandatory - Not Optional)

• Prescribe structured exercise programs including both cardiovascular and resistance training, which reduce pain with effect sizes of 0.57-1.0 1, 2
• Implement patient education programs using individualized packages, group sessions, or phone-based follow-up to improve pain and reduce healthcare utilization 1, 2
• Recommend sustained weight loss for overweight/obese patients (moderate strength recommendation) to reduce joint loading and improve outcomes 1, 2
• Consider assistive devices including walking sticks, insoles, or knee bracing to offload the joint 1

First-Line Pharmacological Treatment

• Acetaminophen (paracetamol) 400-1,000 mg every 4-6 hours, maximum 4,000 mg/day is the preferred initial oral analgesic for long-term use 1, 2
• Topical NSAIDs (particularly diclofenac) have strong evidence for improving function and quality of life with fewer systemic side effects than oral NSAIDs 1, 2

Second-Line Treatment (If Inadequate Response After 2 Weeks)

Oral NSAIDs

• Prescribe oral NSAIDs (ibuprofen 1,200-3,200 mg/day in divided doses) when acetaminophen fails, using the lowest effective dose for shortest duration 1, 3
• Screen for contraindications before prescribing: history of GI ulcers, cardiovascular disease, renal impairment, concurrent anticoagulation 2, 3
• Consider gastroprotection with misoprostol or COX-2 selective inhibitors in patients with increased GI risk 1, 4

Intra-articular Corticosteroids

• Inject long-acting corticosteroids for acute flares, especially when knee effusion is present 1, 2
• Monitor diabetic patients for 1-3 days post-injection due to transient hyperglycemia risk 2
• Avoid injections within 3 months of planned knee replacement due to increased infection risk 2

Adjunctive Therapies (Add to Core Treatment)

Strongly Recommended Additions

• Manual therapy combined with supervised exercise improves pain and function beyond exercise alone 1, 2
• Neuromuscular training (balance, agility, coordination) combined with exercise improves performance-based function and walking speed 1

Limited Evidence but May Consider

• Massage therapy as adjunct to usual care (limited strength recommendation) 1
• TENS (transcutaneous electrical nerve stimulation) for pain relief (limited strength recommendation) 1
• FDA-approved laser treatment (limited strength recommendation) 1

What NOT to Use

• Do NOT prescribe glucosamine or chondroitin - limited evidence despite older recommendations 1, 2
• Do NOT initiate opioids (including tramadol) - poor risk-benefit ratio for new starts 2
• Do NOT use topical capsaicin - conditionally recommended against 2
• Do NOT delay exercise therapy - it is as critical as pharmacological management 2

Critical Pitfalls to Avoid

• Never use NSAIDs without GI/CV/renal screening - NSAID-related GI effects cause significant morbidity and mortality 1, 4
• Do not administer ibuprofen within 8 hours before aspirin - it interferes with aspirin's antiplatelet activity 3
• Avoid both corticosteroid and hyaluronic acid injections near surgery - increases infection risk 2
• Do not prescribe NSAIDs on standing basis - use lowest dose for shortest time, consider as-needed dosing given variable pain intensity 3, 4

Treatment Algorithm Summary

The 2022 AAOS guidelines provide the most current framework 1, which differs slightly from older 2003 EULAR recommendations 1 that suggested paracetamol first-line. The key difference is that modern guidelines give equal strong recommendations to both acetaminophen and NSAIDs (oral/topical), recognizing that combination therapy with non-pharmacological interventions is superior to monotherapy 2, 5. The multimodal approach combining SYSADOAs, NSAIDs, exercise, and education provides better outcomes than single-agent therapy 5.