What are the recommended treatment options for osteoarthritis, including non‑pharmacologic measures, pharmacologic therapy, and indications for intra‑articular injections or surgery?

Osteoarthritis Treatment

All patients with osteoarthritis should immediately begin a structured exercise program (land-based or aquatic) combined with weight loss counseling if overweight, alongside topical NSAIDs for knee OA or oral NSAIDs for hip/hand OA as first-line pharmacologic therapy. 1, 2, 3

Non-Pharmacologic Interventions (Foundation of Treatment)

Strongly Recommended for All Patients

• Exercise programs are the cornerstone of OA management and should be prescribed to every patient regardless of joint involvement 1, 3

  • Land-based cardiovascular and/or resistance exercise targeting quadriceps strengthening (5-7 isometric contractions, 3-5 times daily) combined with ≥30 minutes daily of aerobic activity 1, 3
  • Aquatic exercise provides equivalent pain relief and is preferred when patients have severe pain or difficulty with weight-bearing activities 1, 3
  • Progress intensity from moderate to vigorous over several months, performed at least 2 days per week 3

• Weight loss counseling is mandatory for all overweight or obese patients with any joint involvement, as it improves pain, function, and stiffness without adverse effects 1, 3

Conditionally Recommended Adjuncts

• Self-management programs that teach activity pacing and integrate exercises into daily routines (linking to meals or showering) improve adherence 1, 3
• Manual therapy combined with supervised exercise (not manual therapy alone) 1, 3
• Walking aids should be prescribed when needed to reduce adverse mechanical joint loading 1, 3
• Thermal agents (heat or cold applications) for symptomatic relief 1, 3
• Tai chi for knee OA specifically 1
• Joint protection techniques and assistive devices for hand OA 1
• Trapeziometacarpal joint splints for hand OA 1

Pharmacologic Treatment Algorithm

First-Line Pharmacologic Therapy

For Knee OA:

• Topical NSAIDs are the preferred initial pharmacologic agent, especially in patients ≥75 years, providing local anti-inflammatory effects with fewer systemic adverse events 1, 2, 3
• Acetaminophen up to 4,000 mg/day is an alternative first-line option due to favorable safety profile, though analgesic efficacy is modestly lower than NSAIDs 1, 2, 3

For Hip OA:

• Oral NSAIDs or acetaminophen are conditionally recommended as initial therapy 1
• Topical NSAIDs have insufficient data for hip OA 1

For Hand OA:

• Oral NSAIDs or topical NSAIDs are conditionally recommended 1
• Topical capsaicin may be considered 1

Second-Line Pharmacologic Therapy (When First-Line Fails)

• Oral NSAIDs at the lowest effective dose for the shortest duration if acetaminophen or topical NSAIDs provide inadequate relief 1, 2, 3

  • In patients ≥75 years, continue to favor topical NSAIDs over oral formulations 2, 3
  • For patients with GI risk factors: use COX-2 selective inhibitor OR non-selective NSAID plus proton pump inhibitor 1, 3
  • All oral NSAIDs have similar analgesic efficacy but vary in GI, hepatic, and cardiorenal toxicity 1, 3

• Tramadol may be used conditionally for patients who cannot tolerate acetaminophen or NSAIDs 1, 2, 3

• Duloxetine 30-60 mg/day is conditionally recommended for inadequate response to initial treatments 1, 2, 3

Intra-Articular Injections

• Intra-articular corticosteroid injections are strongly recommended for knee and hip OA, particularly for acute exacerbations with joint effusion 1, 2, 3

• Intra-articular hyaluronate injections are conditionally recommended only for knee OA patients with inadequate response to initial therapy 1, 2

  • No recommendation for hip OA due to lack of data 1

Last-Resort Pharmacologic Options

• Opioid analgesics are strongly recommended ONLY for patients who have failed both non-pharmacologic and pharmacologic modalities AND are either unwilling to undergo or have contraindications to total joint arthroplasty 1

Treatments NOT Recommended

The following should NOT be prescribed:

• Glucosamine and chondroitin supplements lack evidence of clinical benefit 1, 2, 3
• Hyaluronic acid injections are not recommended for routine use 2, 3
• Acupuncture shows no statistically or clinically significant benefit 3
• Lateral wedge insoles lack evidence of effectiveness 3
• Long-term opioid therapy is not supported by evidence 3
• Hyperacute serum should be considered investigational only due to insufficient evidence for efficacy, safety, standardization, and cost-effectiveness 2

Surgical Indications

• Total joint arthroplasty is indicated for patients with chronic moderate to severe pain who have failed comprehensive medical management (both non-pharmacologic and pharmacologic therapies) 1

Critical Implementation Points

Common Pitfalls to Avoid:

• Do not prescribe oral NSAIDs as first-line in elderly patients (≥75 years) when topical NSAIDs are available for knee OA 2, 3
• Do not continue acetaminophen if inadequate response after appropriate trial; escalate to NSAIDs 2, 3
• Do not prescribe opioids before exhausting all other options and surgical evaluation 1
• Do not neglect non-pharmacologic interventions—they are as important as medications and should be initiated simultaneously, not sequentially 1, 3

Monitoring Requirements:

• Regularly reassess pain, function, and treatment response 3
• Monitor for NSAID-related GI and cardiovascular adverse effects, particularly in elderly patients and those with comorbidities 1, 3
• Adjust therapy based on response rather than rigidly continuing a single treatment 4