Management[edit]
Lifestyle modification (such as weight loss and exercise) and analgesics are the mainstay of treatment. Acetaminophen (also known as paracetamol) is recommended first line with NSAIDs being used as add on therapy only if pain relief is not sufficient.[45] This is due to the relative greater safety of acetaminophen.[45]
Lifestyle modification[edit]
For overweight people, weight loss may be an important factor.[46] Patient education has been shown to be helpful in the self-management of arthritis.[46] It decreases pain, improves function, reduces stiffness and fatigue, and reduces medical usage.[46] Patient education can provide on average 20% more pain relief when compared to NSAIDs alone in patients with hip OA.[46]
Physical measures[edit]
Moderate exercise is beneficial with respect to pain and function in those with osteoarthritis of the knee and hip.[47][48] These exercises should occur at least three times per week.[49] While some evidence supports certain physical therapies, evidence for a combined program is limited.[50] There is not enough evidence to determine the effectiveness of massage therapy.[51] The evidence for manual therapy is inconclusive.[52] Functional, gait, and balance training has been recommended to address impairments of position sense, balance, and strength in individuals with lower extremity arthritis as these can contribute to higher falls in older individuals.[53]
Lateral wedge insoles do not appear to be useful in osteoarthritis of the knee.[54][55] Knee braces may be useful.[56] For pain management heat can be used to relieve stiffness, and cold can relieve muscle spasms and pain.[57]
Medication[edit]
| Treatment recommendations by risk factors | ||
|---|---|---|
| GI risk | Stroke and heart risk | Option |
| Low | Low | NSAID, or paracetamol[58] |
| Moderate | Low | Paracetamol, or low dose NSAID withantacid[58] |
| Low | Moderate | Paracetamol, or low dose aspirin with an antacid[58] |
| Moderate | Moderate | Low dose paracetamol, aspirin, and antacid. Monitoring for abdominal pain or black stool.[58] |
The analgesic acetaminophen is the first line treatment for OA.[45][59]However, a 2015 review found acetaminophen to only have a small short term benefit.[60] For mild to moderate symptoms effectiveness is similar to non-steroidal anti-inflammatory drugs (NSAIDs), though for more severe symptoms NSAIDs may be more effective.[45] NSAIDs such as naproxen while more effective in severe cases are associated with greater side effects such as gastrointestinal bleeding.[45] Another class of NSAIDs, COX-2 selective inhibitors(such as celecoxib) are equally effective to NSAIDs with lower rates of adverse gastrointestinal effects but higher rates of cardiovascular disease such as myocardial infarction.[61] They are also more expensive than non-specific NSAIDs.[62] Oral opioids, including both weak opioids such as tramadol and stronger opioids, are also often prescribed. Their appropriateness is uncertain and opioids are often recommended only when first line therapies have failed or are contraindicated.[63][63][64] This is due to a small benefit and relatively large risk of side effects.[65] Oral steroids are not recommended in the treatment of OA.[59]
There are several NSAIDs available for topical use including diclofenac. Topical and oral diclofenac work equally well with topical having a greater risk of mild skin reactions but no greater risk of gastrointestinal adverse effects.[66] Transdermal opioid pain medications are not typically recommended in the treatment of osteoarthritis.[67] Topical capsaicin is controversial with some reviews finding benefit[68][69] and others not.[70]
Joint injections of glucocorticoids (such as hydrocortisone) leads to short term pain relief that may last between a few weeks and a few months.[71] Injections of hyaluronic acidhave not been found to lead to much improvement compared to placebo[72][73] but have been associated with harm.[73] The effectiveness of injections of platelet-rich plasma is unclear; there are suggestions that such injections improve function but not pain and are associated with increased risk.[vague][74][75]
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