What is the recommended treatment for knee degenerative joint disease (osteoarthritis) in an older adult?

Treatment for Knee Degenerative Joint Disease (Osteoarthritis)

Start with core non-pharmacological treatments—exercise, weight loss if overweight, and patient education—for every patient with knee osteoarthritis, then add paracetamol (acetaminophen) or topical NSAIDs for pain relief before considering oral NSAIDs or other interventions. 1, 2, 3

Core Treatments (Required for All Patients)

These foundational interventions must be offered first and maintained throughout treatment:

• Exercise and physical activity: Include local muscle strengthening exercises and general aerobic fitness training, which directly improve pain, function, and delay need for surgery. 1, 2, 3

• Weight loss interventions: If the patient is overweight or obese, weight reduction directly decreases joint loading and provides significant pain relief and functional improvement. 1, 2, 3, 4

• Patient education: Counter the common misconception that osteoarthritis is inevitably progressive and untreatable—provide written and oral information emphasizing that effective treatments exist. 1, 2, 3

Pharmacological Treatment Algorithm

Follow this stepwise approach, escalating only when prior steps provide insufficient relief:

First-Line: Paracetamol (Acetaminophen)

• Start with regular paracetamol dosing up to 4000 mg daily for pain relief, though consider staying at or below 3000 mg daily in elderly patients for enhanced safety. 1, 2, 3

Second-Line: Topical NSAIDs

• If paracetamol is insufficient, add or substitute topical NSAIDs (such as diclofenac gel) before considering oral NSAIDs—topical agents have minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications. 1, 2, 3

Third-Line: Oral NSAIDs or COX-2 Inhibitors

• Use oral NSAIDs or COX-2 inhibitors only at the lowest effective dose for the shortest possible duration when topical agents and paracetamol fail. 1, 3, 5

• Always co-prescribe a proton pump inhibitor with any oral NSAID or COX-2 inhibitor for gastroprotection—this is non-negotiable. 1, 3

• Carefully assess cardiovascular, gastrointestinal, and renal risk factors before prescribing oral NSAIDs, particularly in patients over 50 years who face substantially higher risks of GI bleeding, renal insufficiency, and cardiovascular complications. 2, 3

Fourth-Line: Opioid Analgesics

• Consider carefully titrated opioid analgesics only for severe refractory pain when NSAIDs are contraindicated, ineffective, or poorly tolerated—this is a last-resort option. 1, 6

Additional Adjunctive Non-Pharmacological Treatments

These can be added to core treatments for supplementary benefit:

• Local heat or cold applications (ice packs): Use as adjunctive therapy to enhance comfort while core treatments address underlying disease. 1, 2, 3

• Transcutaneous electrical nerve stimulation (TENS): Consider for additional pain relief. 1, 3

• Manual therapy (manipulation and stretching): Particularly beneficial for hip osteoarthritis, though can be considered for knee. 1, 3

• Assistive devices: Walking sticks, bracing, joint supports, or insoles for those with biomechanical joint pain or instability—seek expert advice from occupational therapists. 1, 4

• Self-management strategies: Target positive behavioral changes including pacing activities (avoiding "peaks and troughs"), using appropriate footwear with shock-absorbing properties. 1

Intra-Articular Injections

• Intra-articular corticosteroid injections: Consider for moderate to severe pain, especially with evidence of inflammation and joint effusion—provides effective short-term pain relief lasting 3-4 weeks. 1, 3, 6

• Intra-articular hyaluronic acid injections are NOT recommended—NICE guidelines explicitly advise against their use despite widespread marketing, as evidence does not support efficacy. 1, 6

Surgical Referral Criteria

• Refer for joint replacement surgery when joint symptoms (pain, stiffness, reduced function) substantially affect quality of life and are refractory to non-surgical treatment—but only after ensuring the patient has been offered at least the core treatment options. 1

• Refer before there is prolonged and established functional limitation and severe pain—earlier referral improves outcomes. 1

• Patient-specific factors (age, sex, smoking, obesity, comorbidities) should NOT be barriers to referral for joint replacement surgery. 1

• Do NOT routinely refer for arthroscopic lavage and debridement unless the patient has a clear history of mechanical locking—not for "giving way," gelling, or x-ray evidence of loose bodies. 1

Critical Pitfalls to Avoid

• Never exceed 4000 mg daily of paracetamol, and strongly consider lower limits (3000 mg) in elderly patients to prevent hepatotoxicity. 2, 3

• Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor co-prescription)—this prevents serious GI bleeding. 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. 2, 3

• Do not use glucosamine, chondroitin, rubefacients, or electroacupuncture—these are not recommended due to insufficient evidence or lack of efficacy. 1

• Do not allow adjunctive treatments to substitute for core interventions—exercise, weight loss, and education must remain the foundation. 2, 6