osteoarthritis
OSTEOARTHRITIS

Osteoarthritis is a chronic progressive disease where there is degeneration and loss of articular cartilage that occurs together with new bone formation at the joint surfaces and margins that causes pain and deformity.

The patient experiences pain, stiffness, decreased movement, inflammation and crepitus.

The pain is usually aggravated by pain and relieved by rest.

Osteoarthritis Treatment

Principles of Therapy

  • Goals in treating patients with osteoarthritis include reducing joint pain and stiffness, maintaining and improving joint mobility, decreasing physical disability, improving quality of life, limiting progression of joint damage and keeping the patient knowledgeable on the nature of their disease and management
  • Used together with pharmacotherapy to decrease pain and improve functioning and quality of life
  • Drug therapy for pain management is most effective when combined with non-pharmacological therapy
  • Symptom management is achieved with pain medications which lead to improvement in functional status and disability
  • Initial management should use agents with the least potential for systemic toxicity or exposure, taking into consideration the patient's medical status

Pharmacotherapy

Oral Analgesics

Paracetamol

  • Oral non-opioid analgesic of choice for patients with mild-moderate pain due to its safety and efficacy profile
    • Should be considered 1st prior to using NSAIDs or opioids
    • Drug of choice for analgesia in patients with impaired renal function
  • Preferred analgesic drug for long-term use, but should be used with caution in patients with liver impairment
  • Pure analgesic with no disease-modifying property

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

  • Eg (Acetic acid derivatives) Aceclofenac, Acemetacin, Diclofenac, Etodolac, Indomethacin, Proglumetacin, Sulindac, Tolmetin; (Coxibs) Celecoxib, Etoricoxib; (Anthranilic acid derivatives) Meclofenamate, Mefenamic Acid; (Oxicam derivatives) Meloxicam, Piroxicam, Tenoxicam; (Propionic acid derivatives) Dexketoprofen, Fenoprofen, Flurbiprofen, Ibuprofen, Ketoprofen, Loxoprofen, Naproxen, Tiaprofenic acid; (Other NSAIDs) Diflunisal, Nabumetone, Nimesulide 
  • Used for treating acute pain due to anti-inflammatory and anti-nociceptive effect and have no disease-modifying effect
  • Oral NSAIDs are strongly recommended for patients with hand, knee and/or hip osteoarthritis 
  • Added to or substituted for Paracetamol or topical NSAIDs when it is insufficient or ineffective in initially relieving osteoarthritis pain
  • Combination with Paracetamol is effective in managing pain with lower NSAID dose and possible toxicity
  • Alternative to Paracetamol for managing osteoarthritis pain due to its relative toxicity
    • Any NSAID monotherapy may be used if patient is at low risk for both gastrointestinal (GI) and cardiovascular (CV) diseases
    • For patients at high risk for CV diseases but with low GI risk, Naproxen or COX-2-selective NSAIDs may be considered
      • Celecoxib is preferred over non-selective NSAIDs for its lesser adverse effects
    • For patients at high risk for GI disease but with low CV risk, COX-2-selective NSAID alone or non-selective NSAIDs in combination with a proton pump inhibitor (PPI) may be considered
    • In patients with both high CV and GI risk or with frailty, NSAIDs therapy should be deferred 
    • Should be used for the shortest possible period of time at the lowest effective dose
    • Increase to full anti-inflammatory doses only if lower doses do not provide adequate symptomatic relief
  • Other analgesics should be considered before adding or substituting an NSAID or COX-2 inhibitor (with concomitant PPI) if pain relief is insufficient or ineffective in patients with osteoarthritis who need to take low-dose Aspirin   

Drugs for Neuropathic Pain

  • Eg Duloxetine
  • Studies have shown that Duloxetine significantly reduced pain and improved function in patients suffering from pain due to knee osteoarthritis
  • Recommended for treatment of chronic musculoskeletal pain and discomfort caused by osteoarthritis
  • Conditionally recommended for patients with hand and/or hip osteoarthritis, knee osteoarthritis who had treatment failure after initial therapy, and symptomatic knee osteoarthritis patients who had inadequate clinical response after non-pharmacologic and pharmacologic treatment who are unwilling or not qualified to undergo total joint arthroplasty

Opioids

  • Eg Dihydrocodeine, Oxycodone, Tramadol
  • Acute pain can often be managed without opioids; 3 days or less and not greater than 7 days will often be sufficient for opioid prescription  
  • Recommended in patients with moderate-severe osteoarthritis pain who have failed to respond to, or unable to tolerate pharmacologic and non-pharmacologic treatments and are unwilling or unqualified to undergo total joint arthroplasty
  • Tramadol is conditionally recommended over other opioids for hand, knee and/or hip osteoarthritis
  • Non-narcotic opioids may be combined with Paracetamol to provide similar analgesic effect
    • If used for acute pain, the lowest possible effective dose and exact quantity of immediate-release opioids should be prescribed 
  • Narcotic opioids may be an option in managing patients with inadequate response or contraindications to other analgesics
    • May cause CNS depression or addiction and lacks disease-modifying properties

Symptomatic Slow-acting Drugs for Osteoarthritis

  • Chondroitin and Glucosamine 
    • Naturally present in the articular cartilage that acts on its formation and repair
      • Suggested as a disease-modifying osteoarthritis drug by some clinical studies
    • Requires 4-12 weeks of therapy before symptom improvement is noted
      • Should discontinue after 6 months of use if no apparent response is noted
    • Use only pharmaceutical-grade prescription Chondroitin and Glucosamine for knee osteoarthritis 
    • Chondroitin sulfate is conditionally recommended in hand osteoarthritis
  • Diacerein 
    • Metabolized to rhein, it stimulates prostaglandin E2 synthesis while inhibiting production of interleukin-1
    • Clinically modest but statistically significant improvement in pain resulting from knee and/or hip osteoarthritis
  • Avocado-Soybean Unsaponifiables (ASU) 
    • A combination of 1/3 avocado oil and 2/3 soya oil, used as a dietary supplement
    • Possibly reduces pain and stiffness during walking and other daily activities, and improves joint function in patients with knee and/or hip osteoarthritis

Topical Analgesics

  • Used as an adjunctive treatment in patients with knee or hand osteoarthritis who have mild-moderate pain who do not respond to Paracetamol and do not want to use systemic therapy
  • Not recommended for hip osteoarthritis
  • Topical NSAIDs have similar efficacy with oral NSAIDs in treating patients with osteoarthritis pain as shown by clinical trials
    • Produce high concentration of the drug at the local site with reduced systemic side effects
    • Recommended for knee (strongly recommended) or hand osteoarthritis (conditionally recommended) as one of the initial management 
    • For patients ≥75 years of age, it is recommended to use topical NSAIDs rather than oral NSAIDs
  • Capsaicin cream causes depletion of substance P neuropeptide causing decreased sensation in the local area
    • May be considered as an adjunctive treatment for knee (conditionally recommended) and/or hand osteoarthritis
  • Salicylate-containing products has a short-term benefit in decreasing pain by increasing local blood flow

Intra-articular Injections

  • Indicated only if non-pharmacotherapy and systemic therapies have failed or are contraindicated
  • Corticosteroids
    • Indicated for fast and short-term relief of pain and swelling of joints
    • Strongly recommended for patients with knee and/or hip (ultrasound-guided) osteoarthritis, conditionally recommended for hand osteoarthritis
    • Synovial fluid is 1st aspirated from the joint to reduce swelling and it allows a higher concentration of the drug at the site of action with a lower risk of systemic side effects
    • Large joints should not be injected for >3x/year and smaller joints for >4x/year
    • Interval of injections to the same joint should not be shorter than 3 months
  • Hyaluronic acid
    • A naturally occurring substance that contributes to the elasticity and lubrication of synovium and cartilage within the joints
      • Currently indicated as a viscoelastic supplementation
    • Conditionally recommended for the treatment of knee osteoarthritis but not recommended for hip or polyarticular osteoarthritis
      • Associated with pain improvement at and beyond 12 weeks and showed a favorable long-term safety profile

 

Non-Pharmacological Therapy

Exercise

  • Eg local muscle strengthening, resistance training, aerobic or flexibility exercises
  • Strongly recommended in the management strategy of patients with hand, knee and/or hip osteoarthritis for both prevention and treatment of symptoms
  • Should be individualized according to the patient’s needs, abilities and preferences and availability of facilities
  • Improves general physical health, reduces risk for development of chronic diseases and helps in weight control
    • May also improve patient’s overall quality of life through its psychological and social benefits
    • Helps to improve physical functioning and reduce pain in patients with knee osteoarthritis through increased muscle strength, range of motion, aerobic capacity and endurance
  • High-quality evidence from different studies show that exercise therapy reduces pain and improves function immediately after treatment for hip or knee osteoarthritis
  • Guidelines have strongly recommended strengthening, walking, neuromuscular training and aquatic exercises for patients with osteoarthritis of the knee and hip
  • Land and aquatic exercises are both recommended for patients with symptomatic knee and hip osteoarthritis
    • The choice between land and aquatic exercises depend on the patient’s preference and ability
    • Aquatic exercises are preferred for patients with hip osteoarthritis because of lesser stress to the joints due to buoyancy
  • Several studies have shown pain improvement in patients practicing tai chi as compared to those without exercise 
    • Tai chi is strongly recommended for patients with knee and/or hip osteoarthritis
  • Yoga is conditionally recommended for patients with knee OA

Weight Reduction

  • Patients with symptomatic osteoarthritis, especially of the knee and/or hip, should be encouraged to lose ≥5% of their body weight and maintain their weight at a lower level with an appropriate program of dietary modification and exercise

Physical Therapy

  • Eg range of motion exercises, soft tissue mobilization, muscle strengthening and stretching
  • Employed in addition to active exercise programs that aims to relieve pain and stiffness, and improve joint movement and overall function
  • Balance training is conditionally recommended for patients with knee and/or hip osteoarthritis

Thermotherapy

  • Adjunctive treatment conditionally recommended for hand, knee and/or hip osteoarthritis
  • Involves local application of heat or cold to manage symptoms of osteoarthritis of the hand, knee and hip
  • Cold therapy is most effective during acute flare of osteoarthritis which reduces inflammation and pain, blocks nerve impulses and muscle spasms to the joint
    • Applied in the affected area for 20 minutes, 5 days/week for 2 weeks
  • Heat therapy applied for 15-20 minutes may reduce pain and stiffness by promoting relaxation, joint flexibility and blood flow to the joint
    • Paraffin is conditionally recommended for hand osteoarthritis

Mechanical Interventions

Assist Devices

  • Jar openers, key turners and pull tabs are recommended for patients with hand osteoarthritis

Hand Orthosis

  • Neoprene or rigid orthoses for 1st CMC joint osteoarthritis are strongly recommended; orthoses for other hand joints are conditionally recommended  
  • Splints are conditionally recommended for patients with trapeziometacarpal joint osteoarthritis

Knee Braces

  • Maintain the joint in a fixed position 
  • May increase stability, support weak muscles and joints, and redistribute weight load to the joint
    • May also help decrease the risk of falling
  • A tibiofemoral (TF) brace is strongly recommended for TF osteoarthritis while a patellofemoral (PF) brace is conditionally recommended for PF osteoarthritis

Taping

  • Patellar taping may be used for short-term, intermittent treatment of knee osteoarthritis by stabilizing the knee joint and distributing stress and joint pressure
    • Medially directed patellar taping is recommended for knee osteoarthritis
  • Kinesiotaping allows joint range of motion  
    • Conditionally recommended for hand (1st CMC joint) and/or knee osteoarthritis

Walking Aids

  • A cane is strongly recommended for patients with knee and/or hip osteoarthritis wherein ≥1 affected joints cause pain or affect ambulation or joint stability

Wedge Insoles

  • May be considered as an adjunctive treatment to provide pain relief and improve ambulation in patients with knee and/or hip osteoarthritis
  • Medially-wedged insoles - conditionally recommended for patients with lateral compartment osteoarthritis
  • Laterally-wedged subtalar strapped insoles - conditionally recommended for patients with medial compartment osteoarthritis

Alternative Therapy

Acupuncture

  • Conditionally recommended for hand, knee and/or hip osteoarthritis
  • May be used as an adjunctive treatment for symptomatic relief of pain and improvement of knee function by triggering the endogenous opioid pathways
    • Used for knee osteoarthritis patients with chronic moderate to severe pain who are unwilling or not qualified for knee arthroplasty

Transcutaneous Electrical Nerve Stimulation (TENS)

  • May be considered as an adjunctive treatment for pain relief in patients with osteoarthritis 
  • Non-invasive therapy that relieves pain by inhibiting the transmission of painful stimuli
  • Provides short-term relief of osteoarthritis knee pain, reduces stiffness and improves range of motion
    • Effects last for 4 weeks

Manual Therapy

  • Eg Stretching, mobilization/manipulation, manual traction, massage
  • May be considered as an adjunctive treatment in knee and/or hip osteoarthritis 

Radiofrequency Ablation

  • Some studies have shown potential analgesic effect but data on long-term safety is lacking  
  • Conditionally recommended for knee osteoarthritis  

Cognitive Behavioral Therapy (CBT)

  • Conditionally recommended for hand, knee and/or hip osteoarthritis as there is limited evidence that suggests CBT may decrease osteoarthritis pain
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Rheumatology digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
Pearl Toh, 22 Oct 2020
The combination therapy comprising carfilzomib, cyclophosphamide and dexamethasone (KCd) is effective, with a tolerable safety profile, in an Asian cohort with high-risk multiple myeloma (MM) — thus providing a more economical alternative as a potential upfront regimen in resource-limited settings, according to leading experts during a myeloma education webinar.
Roshini Claire Anthony, 13 Nov 2020

Diabetes is a key risk factor for heart failure (HF), which is the leading cause of hospitalization in patients with or without diabetes. SGLT-2* inhibitors (SGLT-2is) have been shown to reduce the risk of hospitalization for HF (HHF) regardless of the presence or absence of diabetes.

Pearl Toh, 6 days ago
Inhaled corticosteroid (ICS) should be the mainstay of long-term asthma management — such is the key message of the latest Singapore ACE* Clinical Guidance (ACG) for asthma, released in October 2020.
Elvira Manzano, 17 Nov 2020
Invasive fungal infections, particularly those caused by Candida species, are common in hospitalized, immunocompromised, or critically ill patients and are associated with considerable morbidity and mortality.