What are the treatment options for an adult patient with osteoarthritis?

Treatment for Osteoarthritis in Adults

All adults with osteoarthritis should receive three mandatory core treatments—exercise (including local muscle strengthening and general aerobic fitness), weight loss interventions if overweight or obese, and patient education—before or alongside any pharmacological therapy. 1, 2, 3

Core Non-Pharmacological Treatments (Mandatory First-Line)

These interventions form the foundation of osteoarthritis management and should be implemented for every patient, as they directly improve morbidity and quality of life:

• Exercise therapy is strongly recommended and includes land-based strengthening exercises, general aerobic fitness activities, and aquatic exercise programs 2, 3, 4

  • Local muscle strengthening around affected joints reduces pain and improves function 1
  • Aquatic exercise provides joint-sparing cardiovascular conditioning 4

• Weight loss interventions are mandatory for patients with BMI ≥25 kg/m², as even 5-10% body weight reduction significantly decreases mechanical stress on weight-bearing joints 1, 2, 3

• Patient education must address misconceptions (particularly that osteoarthritis is inevitably progressive and untreatable) and enhance self-management strategies 1, 3

Adjunct Non-Pharmacological Interventions

After establishing core treatments, add these modalities based on specific joint involvement and functional limitations:

• Assistive devices and supports reduce joint load: walking sticks for hip/knee osteoarthritis, braces for tibiofemoral or patellofemoral osteoarthritis, and orthoses for first carpometacarpal joint osteoarthritis 1, 3

• Physical modalities for symptomatic relief include local heat or cold applications, transcutaneous electrical nerve stimulation (TENS), and manipulation/stretching (particularly beneficial for hip osteoarthritis) 1, 3

• Behavioral modifications such as wearing shock-absorbing footwear and pacing activities to avoid overexertion 1

Pharmacological Treatment Algorithm

Step 1: First-Line Oral Analgesic

• Start with acetaminophen (paracetamol) up to 4,000 mg/day in divided doses, with regular dosing often needed for sustained effect 1, 3
• This is the safest first-line option, though recent evidence suggests limited efficacy compared to NSAIDs 3, 5

Step 2: Topical NSAIDs (Especially for Knee and Hand Osteoarthritis)

• Topical NSAIDs are strongly recommended before oral NSAIDs for accessible joints (knee, hand) as they provide effective pain relief with minimal systemic exposure and fewer adverse effects 1, 3
• Topical capsaicin can also be considered for localized pain 1

Step 3: Oral NSAIDs or COX-2 Inhibitors

• If acetaminophen and topical NSAIDs provide insufficient relief, add or substitute with oral NSAIDs or COX-2 inhibitors 1
• Use at the lowest effective dose for the shortest possible duration 1, 3
• Mandatory gastroprotection: Prescribe alongside a proton pump inhibitor (choose the lowest acquisition cost option) 1
• First choice should be either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID 1

Critical Safety Considerations for NSAIDs:

• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing, particularly in elderly patients 1, 6
• NSAIDs increase risk of serious cardiovascular events (myocardial infarction, stroke), especially with longer use and in patients with heart disease 6
• Never use NSAIDs immediately before or after coronary artery bypass graft (CABG) surgery 6
• Risk of ulcers and bleeding increases with corticosteroid or anticoagulant use, longer duration, smoking, alcohol consumption, older age, and poor health 6
• Naproxen has been demonstrated to cause statistically significantly less gastric bleeding and erosion than aspirin in controlled studies 6

Step 4: Alternative Oral Medications

• Duloxetine is conditionally recommended for patients with inadequate response to first-line treatments or those with comorbid depression 3, 5
• Tramadol is conditionally recommended only when other options have failed, but carries significant risks of dependence and side effects 3, 5
• Opioid analgesics may be added if paracetamol or topical NSAIDs are insufficient, though they should be used cautiously 1

Step 5: Intra-Articular Injections

• Corticosteroid injections are strongly recommended for knee and hip osteoarthritis to provide short-term pain relief (particularly during flares or for moderate to severe pain) 1, 3
• These have relatively minor adverse effects and can be repeated as needed 3, 5

Treatments NOT Recommended

The following interventions lack sufficient evidence or have been shown ineffective and should be avoided:

• Glucosamine and chondroitin products are not recommended despite popular use, as they have not shown significant benefits over placebo 1, 3
• Electroacupuncture should not be used 1, 3
• Acupuncture has insufficient evidence to make a firm recommendation despite some RCTs 1

Common Pitfalls and Caveats

Risk Assessment Before NSAID Use:

• Always evaluate cardiovascular risk (history of heart disease, hypertension), gastrointestinal risk (prior ulcers, concurrent anticoagulant/corticosteroid use), and renal function before prescribing oral NSAIDs 1, 6
• In elderly patients or those with multiple comorbidities, strongly favor topical NSAIDs over oral formulations 3, 5

Monitoring and Periodic Review:

• Provide tailored periodic review as disease course and patient needs change over time 1, 7
• Reassess treatment effectiveness regularly rather than rigidly continuing a single treatment 7

Combination Therapy:

• NSAIDs combined with salicylates is not recommended, as aspirin increases naproxen excretion and the combination may result in higher frequency of adverse events 6
• Naproxen may be used safely with gold salts and/or corticosteroids 6

Formulating the Management Plan:

• Develop the plan in partnership with the patient, taking into consideration comorbidities that compound osteoarthritis effects 1
• Communicate risks and benefits in understandable ways 1
• Assess the effect on function, quality of life, occupation, mood, relationships, and leisure activities 1