What is the best medication for an adult patient with arthritis?

Best Medication for Arthritis

Start with acetaminophen (paracetamol) at regular doses up to 4000 mg daily as your first-line medication for osteoarthritis, as it provides effective pain relief with the safest profile compared to all other pharmacologic options. 1, 2

First-Line Treatment: Acetaminophen

• Acetaminophen is the preferred initial medication for arthritis pain, using regular scheduled dosing rather than "as needed" for better sustained pain control 2, 3
• Maximum daily dose is 4000 mg (4 grams), though consider staying at or below 3000 mg daily in elderly patients to prevent hepatotoxicity 2, 3
• Regular dosing throughout the day may be needed for adequate symptom control 1

Second-Line: Topical NSAIDs Before Oral NSAIDs

If acetaminophen provides insufficient relief:

• Apply topical NSAIDs (such as diclofenac gel) before considering oral NSAIDs, as they have minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications 2, 3
• Topical capsaicin is an alternative localized agent that may provide pain relief 1, 2
• For knee and hand osteoarthritis specifically, topical NSAIDs are particularly recommended before oral options 1

Third-Line: Oral NSAIDs or COX-2 Inhibitors

Only when topical treatments have failed:

• Prescribe oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible duration 1
• The first choice should be either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID 1
• Always co-prescribe a proton pump inhibitor alongside any oral NSAID or COX-2 inhibitor for gastroprotection, choosing the one with lowest acquisition cost 1, 2
• All oral NSAIDs and COX-2 inhibitors have similar analgesic effects but vary in their gastrointestinal, liver, and cardiorenal toxicity 1

Critical Safety Considerations for NSAIDs

• Carefully assess cardiovascular, gastrointestinal, and renal risk factors before prescribing any oral NSAID, particularly in patients over 50 years 2, 4
• Elderly patients face substantially higher risks of GI bleeding, renal insufficiency, platelet dysfunction, and cardiovascular complications with NSAIDs 2, 4, 3
• Take detailed medication histories including over-the-counter medications, as NSAIDs have considerable risk of drug-drug and drug-disease interactions (heart failure, hypertension, hepatic/renal disease) 2
• If a patient needs low-dose aspirin, consider other analgesics before adding an NSAID or COX-2 inhibitor 1

Fourth-Line: Opioids

• Consider opioid analgesics only when acetaminophen, topical agents, and NSAIDs have failed or are contraindicated 1, 2
• Use opioids cautiously given their side effect profile and addiction potential 2

Additional Treatment Options

• Consider intra-articular corticosteroid injections for moderate to severe pain, especially with evidence of inflammation or joint effusion 1, 2
• These injections can provide significant relief when oral medications are insufficient 1

Essential Non-Pharmacologic Core Treatments (Not Optional)

These must accompany any medication regimen:

• Exercise and physical activity focusing on local muscle strengthening and general aerobic fitness 1, 2, 4
• Weight loss interventions if the patient is overweight or obese, as this reduces joint load and pain 1, 2, 4
• Patient education to counter misconceptions that osteoarthritis is inevitably progressive and cannot be treated 1, 2, 4, 3
• Local heat or cold applications for temporary symptom relief 1, 2, 4
• Assistive devices (such as walking sticks) and shock-absorbing footwear 1, 2

Common Pitfalls to Avoid

• Never exceed 4000 mg daily of acetaminophen, and strongly consider lower limits (3000 mg) in elderly patients 2, 3
• Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor co-prescription) 1, 2, 3
• Avoid prolonged NSAID use at high doses, particularly in elderly patients who are at highest risk for serious adverse events including GI bleeding, renal failure, and cardiovascular complications 1, 2, 3
• Do not use glucosamine or chondroitin products, as current evidence does not support their efficacy 1, 2, 3
• Never overlook non-pharmacologic treatments—they are not optional adjuncts but essential core therapy that must be implemented alongside medications 1, 2, 4

Note on Rheumatoid Arthritis

If the arthritis is rheumatoid arthritis (rather than osteoarthritis), the treatment approach differs significantly and requires disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, or biologic agents like adalimumab or etanercept, which are not appropriate for osteoarthritis 5, 6