What are the management options for a patient with osteoarthritis?

Management of Osteoarthritis

All patients with osteoarthritis should receive three core treatments immediately: exercise therapy (including local muscle strengthening and general aerobic fitness), weight loss interventions if overweight or obese, and patient education to counter misconceptions about the disease. 1

Core First-Line Treatments (Non-Negotiable for All Patients)

These interventions form the foundation of osteoarthritis management and should be initiated before or alongside any other treatments:

Exercise Therapy (Strongly Recommended)

• Exercise is the single most important non-pharmacological intervention and should be prescribed to every patient with knee, hip, or hand osteoarthritis 1
• Multiple exercise modalities are effective, including walking, stationary cycling, resistance training with elastic bands or weight machines, aquatic exercise, and neuromuscular training 1
• No specific exercise type has proven superior to others; choose based on patient preference and accessibility rather than seeking an "optimal" regimen 1
• Patients experiencing pain should not avoid exercise—clinical trials demonstrate that symptomatic patients can participate in and benefit from exercise programs 1
• Referral to physical or occupational therapy is beneficial at various disease stages for proper instruction, self-efficacy training, and maintenance of exercise adherence 1

Weight Loss (If Overweight/Obese)

• Weight reduction is strongly recommended as it directly reduces mechanical stress on weight-bearing joints 1
• This intervention should be implemented early and maintained throughout disease management 1

Patient Education

• Provide both oral and written information to enhance understanding and counter the misconception that osteoarthritis is inevitably progressive and untreatable 1
• Education improves treatment adherence and overall outcomes 1

Pharmacological Treatment Algorithm

Step 1: First-Line Analgesics

• Start with acetaminophen (paracetamol) at regular dosing up to 4,000 mg/day for pain relief 1, 2
• For knee and hand osteoarthritis specifically, use topical NSAIDs before oral NSAIDs due to fewer systemic side effects 1, 2
• Topical capsaicin can be added for additional pain relief in knee and hand osteoarthritis 1

Step 2: Oral NSAIDs/COX-2 Inhibitors (When First-Line Insufficient)

• If acetaminophen and topical NSAIDs fail to provide adequate pain relief, escalate to oral NSAIDs or COX-2 inhibitors 1
• Use the lowest effective dose for the shortest possible duration 1
• Choose either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID 1
• Always co-prescribe a proton pump inhibitor for gastroprotection, selecting the lowest acquisition cost option 1
• Before prescribing, assess cardiovascular, gastrointestinal, liver, and renal risk factors, particularly in elderly patients 1
• Ibuprofen dosing for osteoarthritis: 1200-3200 mg daily (400-800 mg three to four times daily), though doses above 2400 mg rarely provide additional benefit 3
• Naproxen dosing: 375-750 mg twice daily, with the 750 mg twice daily dose associated with higher adverse event rates 4

Step 3: Opioid Analgesics (When NSAIDs Insufficient or Contraindicated)

• Add opioid analgesics if previous treatments are inadequate, recognizing the risks of long-term opioid use 1
• Can be used in combination with acetaminophen or as a substitute 1

Step 4: Intra-articular Injections

• Intra-articular corticosteroid injections are specifically indicated for knee pain with effusion and can provide short-term pain relief during disease flares 5, 6
• Intra-articular hyaluronic acid products may be considered for inadequate pain relief with oral medications 6

Adjunct Non-Pharmacological Treatments

Physical Modalities

• Local heat or cold applications provide temporary pain relief 1
• Transcutaneous electrical nerve stimulation (TENS) can be used for pain management 1
• Manipulation and stretching, particularly for hip osteoarthritis, may provide benefit when combined with exercise 1

Assistive Devices and Supports

• Assess for bracing, joint supports, or insoles in patients with biomechanical joint pain or instability 1
• Provide assistive devices (walking sticks, tap turners) for those with specific problems in activities of daily living 1
• Consider occupational therapy referral for expert assessment 1

Behavioral Modifications

• Recommend appropriate footwear with shock-absorbing properties 1
• Teach activity pacing to avoid "peaks and troughs" of activity that exacerbate symptoms 1

Treatments NOT Recommended

Do not use the following interventions, as evidence does not support their efficacy:

• Glucosamine and chondroitin products are not recommended despite their popularity, as they have not demonstrated significant benefits over placebo 1, 2, 7
• Electroacupuncture should not be used 1
• Traditional acupuncture has insufficient evidence for a firm recommendation 1

Critical Monitoring and Safety Considerations

NSAID Risk Assessment (Essential Before Prescribing)

• All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but differ significantly in gastrointestinal, liver, and cardiorenal toxicity 1
• Age is a major risk factor—elderly patients require particularly careful assessment 1
• Consider ongoing monitoring of risk factors during treatment 1
• Avoid combining NSAIDs with aspirin, as aspirin increases naproxen excretion and the combination increases adverse event frequency without proven additional benefit 4

Periodic Review

• Provide regular follow-up tailored to individual needs, as disease course and patient requirements change over time 1
• Reassess treatment effectiveness and adjust the management plan accordingly 1

Holistic Assessment Framework

At each visit, assess the impact of osteoarthritis on:

• Function and activities of daily living 1
• Quality of life 1
• Occupation and work capacity 1
• Mood and psychological well-being 1
• Relationships and social activities 1
• Leisure activities 1

Formulate the management plan in partnership with the patient, considering comorbidities that compound osteoarthritis effects 1

Surgical Considerations

• Joint replacement surgery should be considered only after offering core treatment options and when conservative management fails to provide adequate pain relief and functional improvement 2
• Arthroscopic procedures have not shown benefit over sham procedures or optimized physical and medical therapy and should be avoided 7
• Surgery is appropriate for patients with joint symptoms that substantially impact quality of life despite comprehensive conservative management 2