What is the recommended treatment for an older adult patient with osteoarthritis, considering potential comorbidities and overall health status?

Treatment for Osteoarthritis in Older Adults

All older adults with osteoarthritis must receive three core treatments first—patient education, exercise (muscle strengthening and aerobic fitness), and weight loss if overweight—before adding any pharmacological therapy. 1

Core Non-Pharmacological Treatments (Required for Every Patient)

These foundational interventions must be implemented before or alongside any medication:

• Patient education to counter the misconception that osteoarthritis is inevitably progressive and untreatable 1
• Exercise programs including local muscle strengthening and general aerobic fitness training 1, 2
• Weight loss interventions if the patient is overweight or obese, as this directly reduces joint loading and pain 1, 2

Pharmacological Treatment Algorithm

First-Line: Paracetamol (Acetaminophen)

Start with paracetamol at regular doses up to 4000 mg daily for pain relief. 1, 2, 3

• Use regular dosing rather than "as needed" for better sustained pain control 3
• In elderly patients, strongly consider staying at or below 3000 mg daily to prevent hepatotoxicity 2, 3
• Paracetamol provides the safest initial pharmacologic option with the best safety profile compared to all alternatives 3

Second-Line: Topical NSAIDs

If paracetamol is insufficient, add or substitute topical NSAIDs (such as diclofenac gel) before considering oral NSAIDs. 1, 2, 4

• Topical NSAIDs have minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications compared to oral formulations 2, 3
• For knee and hand osteoarthritis specifically, topical NSAIDs show strong efficacy (effect size 0.77 for hand OA) 4
• Topical capsaicin is an alternative localized agent with a number needed to treat of 3 patients 1, 4

Third-Line: Oral NSAIDs or COX-2 Inhibitors

Only prescribe oral NSAIDs or COX-2 inhibitors when paracetamol and topical treatments have failed, and use at the lowest effective dose for the shortest possible duration. 1, 3

• 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, 3
• The first choice should be either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID 1
• In elderly patients, carefully assess cardiovascular, gastrointestinal, and renal risk factors before prescribing any oral NSAID, particularly in those over 50 years 2, 3
• Elderly patients face substantially higher risks of GI bleeding, renal insufficiency, platelet dysfunction, and cardiovascular complications with NSAID use 2, 3, 5

Fourth-Line: Opioid Analgesics

Consider adding opioid analgesics only if paracetamol, topical NSAIDs, and oral NSAIDs are insufficient for pain relief. 1

Additional Adjunctive Non-Pharmacological Treatments

After establishing core treatments, consider these supplementary options:

• Local heat or cold applications (ice packs) for supplementary pain relief 1, 2
• Manual therapy (manipulation and stretching), particularly for hip osteoarthritis 1
• Transcutaneous electrical nerve stimulation (TENS) 1
• Assistive devices (walking sticks, tap turners) for those with specific problems in activities of daily living 1
• Bracing, joint supports, or insoles for those with biomechanical joint pain or instability 1
• Shock-absorbing shoes or insoles 1

Intra-Articular Corticosteroid Injections

Consider intra-articular corticosteroid injections for moderate to severe pain relief, particularly in knee osteoarthritis 1

• Generally not recommended for hand osteoarthritis, though may be considered in painful interphalangeal joints 4
• For wrist joints specifically, intraarticular corticosteroids show no significant benefit 4

What NOT to Use

Do not prescribe glucosamine or chondroitin products, as current evidence does not support their efficacy 1, 3

Do not use electroacupuncture 1

Never prescribe conventional or biological disease-modifying antirheumatic drugs (DMARDs) for osteoarthritis—these are contraindicated and should only be used for inflammatory arthritis like rheumatoid arthritis 4

Surgical Referral Considerations

Refer for joint replacement surgery when joint symptoms (pain, stiffness, reduced function) substantially affect quality of life and are refractory to non-surgical treatment. 1

• Referral should occur before there is prolonged and established functional limitation and severe pain 1
• Patient-specific factors (including age, sex, smoking, obesity, and comorbidities) should not be barriers to referral 1
• Do not routinely refer for arthroscopic lavage and debridement unless the patient has knee osteoarthritis with a clear history of mechanical locking 1

Critical Safety Pitfalls to Avoid

• Never exceed 4000 mg daily of paracetamol, and strongly consider lower limits (3000 mg) in elderly patients 2, 3
• Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor co-prescription) 1, 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 2, 3, 5
• In patients taking low-dose aspirin, consider other analgesics before substituting with or adding an NSAID or COX-2 inhibitor (plus a proton pump inhibitor) 1
• Monitor for hepatotoxicity with paracetamol, especially in elderly patients or those with liver disease 3
• Assess for aspirin-sensitive asthma before prescribing NSAIDs, as cross-reactivity can cause severe bronchospasm 5

Comorbidity Considerations

When managing osteoarthritis in older adults with comorbidities:

• Formulate a management plan in partnership with the patient, taking into consideration comorbidities that compound the effect of osteoarthritis 1
• Assess cardiovascular risk factors before prescribing oral NSAIDs, as all oral NSAIDs and COX-2 inhibitors carry cardiovascular thrombotic event risks 1, 2, 5
• Evaluate renal function before and during NSAID therapy, as NSAIDs can cause renal insufficiency, particularly in elderly patients 2, 3, 5
• Screen for gastrointestinal risk factors including history of peptic ulcer disease, GI bleeding, or concurrent anticoagulant use 1, 2, 5
• Monitor hemoglobin/hematocrit in patients on long-term NSAID therapy, as anemia can develop from occult GI blood loss or effects on erythropoiesis 5