What are the recommended non‑pharmacologic and pharmacologic management steps for an adult with osteoarthritis?

Management of Osteoarthritis in Adults

Mandatory Non-Pharmacologic Core Treatments (Must Be Initiated First)

All patients with osteoarthritis must begin with non-pharmacologic core treatments before or alongside any medication, as these interventions directly address disease burden and improve both pain and function. 1, 2

Exercise Therapy (Strongly Recommended)

• Aerobic exercise (land-based or aquatic), resistance training, and local muscle strengthening are strongly recommended for all patients with knee and hip osteoarthritis, regardless of age, disease severity, or pain level. 1, 2
• Aquatic exercise in warm water (86°F) reduces joint loading through buoyancy while providing resistance for muscle strengthening, making it ideal for aerobically deconditioned patients who can later progress to land-based programs. 1
• Tai chi programs are conditionally recommended as a low-impact aerobic option specifically for knee osteoarthritis. 1, 2
• Perform strengthening exercises 5–7 times, 3–5 times daily (before getting out of bed, before climbing stairs, before sleep), holding muscle contractions for 6–7 seconds with 2–3 seconds rest between repetitions. 1

Weight Loss (Strongly Recommended)

• All overweight or obese patients with osteoarthritis must be counseled regarding weight loss, as this directly lowers joint loading, reduces pain, and slows disease progression. 1, 2

Patient Education (Strongly Recommended)

• Provide both oral and written education to correct the misconception that osteoarthritis is inevitably progressive and untreatable, emphasizing self-management strategies. 2, 3

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Pharmacologic Treatment Algorithm (Step-Wise Approach)

Step 1: First-Line Analgesic

Acetaminophen up to 4,000 mg/day (consider ≤3,000 mg/day in elderly for enhanced safety) is the safest initial pharmacologic treatment and should be given on a scheduled basis rather than PRN. 1, 2, 3

• Acetaminophen provides pain relief comparable to NSAIDs without gastrointestinal, renal, or cardiovascular risks. 1
• Critical safety point: Counsel patients to avoid all other acetaminophen-containing products, including over-the-counter cold remedies and combination opioid products. 1

Step 2: Topical Therapy (Before Oral NSAIDs)

For knee and hand osteoarthritis, topical NSAIDs (diclofenac 1–1.5% gel or ketoprofen gel) should be tried before oral NSAIDs because they have minimal systemic absorption and markedly lower gastrointestinal, renal, and cardiovascular risk. 1, 2, 3

• Topical capsaicin may be used as an alternative, but therapeutic benefit requires continuous application for 2–4 weeks. 1, 2
• Note: Topical NSAIDs are conditionally recommended for knee osteoarthritis but have insufficient data for hip osteoarthritis. 1

Step 3: Oral NSAIDs or COX-2 Inhibitors

Oral NSAIDs or selective COX-2 inhibitors should be initiated only after failure of acetaminophen and topical agents, using the lowest effective dose for the shortest duration. 1, 2, 3

• All oral NSAIDs and COX-2 inhibitors provide comparable analgesia but differ significantly in gastrointestinal, hepatic, and cardiorenal toxicity profiles. 2, 3
• A proton-pump inhibitor must be co-prescribed with any oral NSAID or COX-2 inhibitor for gastro-protection. 2, 3
• Mandatory pre-treatment assessment: Carefully evaluate cardiovascular, gastrointestinal, and renal risk factors before prescribing any oral NSAID, particularly in patients older than 50 years. 2, 4, 3
• Elderly patients face substantially higher risks of GI bleeding, renal insufficiency, platelet dysfunction, and cardiovascular complications with NSAID use. 1, 4

Step 4: Intra-Articular Corticosteroid Injections

Intra-articular corticosteroid injections are indicated for moderate-to-severe pain unresponsive to oral medications, providing short-term relief lasting 1–3 weeks, and are especially appropriate when oral NSAIDs are contraindicated. 1, 2

Step 5: Advanced Options for Refractory Disease

• Intra-articular hyaluronate injections may be considered for knee osteoarthritis after inadequate response to earlier therapies (no recommendation for hip due to insufficient data). 1, 2
• Duloxetine is conditionally recommended for patients who have not responded to standard therapy. 1, 2
• Tramadol may be used only after failure of acetaminophen, topical agents, and intra-articular injections, employing slow upward titration to improve tolerability. 1, 2
• Strong opioids are strongly recommended only for patients unwilling or unable to undergo total joint arthroplasty after all other medical therapies have failed. 1, 2

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Joint-Specific Adjunct Non-Pharmacologic Therapies

Knee Osteoarthritis (Conditionally Recommended)

• Medially wedged insoles for lateral compartment (valgus) knee osteoarthritis. 1, 2
• Laterally wedged subtalar-strapped insoles for medial compartment (varus) knee osteoarthritis. 1, 2
• Medially directed patellar taping for symptom relief. 1, 2
• Manual therapy combined with supervised exercise (not manual therapy alone). 1, 2
• Walking aids as needed for mobility support. 1, 2
• Thermal agents (heat or cold applications) for temporary pain relief. 1, 2, 4
• Self-management programs and psychosocial interventions. 1, 2
• Traditional Chinese acupuncture only for patients with chronic moderate-to-severe pain who are candidates for total knee arthroplasty but are unwilling or have contraindications to surgery. 1

Hip Osteoarthritis (Conditionally Recommended)

• Manual therapy combined with supervised exercise. 1, 2
• Thermal agents (heat or cold). 1, 2
• Walking aids and assistive devices. 1, 2
• Self-management programs with psychosocial interventions. 1, 2

Hand Osteoarthritis (Conditionally Recommended)

• Instruction in joint-protection techniques. 1, 2
• Provision of assistive devices. 1, 2
• Trapeziometacarpal (thumb-base) joint splints. 1, 2
• Thermal modalities (heat or cold). 1, 2
• Oral and topical NSAIDs, tramadol, and topical capsaicin. 1

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What NOT to Use (Evidence Does Not Support)

• Glucosamine and chondroitin supplements are conditionally recommended against, as current evidence does not support their efficacy. 1, 2, 3
• Electroacupuncture should not be used based on available evidence. 2, 3
• Arthroscopic lavage and debridement should not be offered routinely unless the patient has knee osteoarthritis with a clear history of mechanical locking. 2

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Surgical Referral Criteria

• Refer patients for total joint replacement when joint symptoms substantially impair quality of life and are refractory to non-surgical treatment, before prolonged functional limitation develops. 2
• Patient-specific factors such as age, sex, smoking status, obesity, or comorbidities should not be barriers to referral for joint replacement. 2

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Critical Safety Monitoring

• Never prescribe an oral NSAID without concurrent gastro-protection (proton-pump inhibitor). 2, 4, 3
• Monitor cardiovascular, gastrointestinal, and renal function during NSAID therapy, especially in elderly patients. 2, 4, 3
• Provide periodic review tailored to individual needs, as disease course and patient requirements change over time. 3, 5