Osteoarthritis Treatment

• Goals in treating patients with osteoarthritis (OA) 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
• Non-pharmacological therapy is used together with pharmacotherapy to decrease pain and improve functioning and quality of life
• Pharmacological therapy should be individualized; 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 and preference
• Combination therapy may be considered if the patient has inadequate response to monotherapy; patient should be regularly assessed and treatment regimen adjusted based on patient response

Topical Analgesics

• Used as an adjunctive treatment in patients with knee or hand osteoarthritis who have mild-moderate pain who do not respond to symptomatic slow-acting drugs for OA and/or Paracetamol and do not want to use systemic therapy
• Not recommended for hip OA
• Topical NSAIDs have similar efficacy with oral NSAIDs in treating patients with OA 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 OA (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 OA
• Salicylate-containing products has a short-term benefit in decreasing pain by increasing local blood flow

Oral Analgesics

Paracetamol (Acetaminophen) 

• 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
• Pure analgesic with no disease-modifying property
• Preferred analgesic drug for long-term use, but should be used with caution in patients with liver impairment
• Lowest clinically effective dose should be used due to its relative hepatic toxicity

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• Eg (acetic acid derivatives) Aceclofenac, Acemetacin, Diclofenac, Etodolac, Indomethacin, Proglumetacin, Sulindac, Tolmetin; (coxibs) Celecoxib, Etoricoxib; (fenamic acid derivatives) Meclofenamate, Mefenamic acid; (oxicam derivatives) Lornoxicam, 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 OA
• Given to symptomatic patients when background therapy with crystalline Glucosamine sulfate and add-on topical NSAIDs and/or Paracetamol are insufficient or ineffective in initially relieving OA pain
• Combination with Paracetamol is effective in managing pain with lower NSAID dose 
• Alternative to Paracetamol for managing OA 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; risks and benefits of Etoricoxib are similar to Celecoxib
  • 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 OA who need to take low-dose Aspirin   

Drugs for Neuropathic Pain

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

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 due to safety and potential dependency concerns
• Recommended in patients with moderate-severe OA pain who have failed to respond to, or unable to tolerate pharmacologic and non-pharmacologic treatments and are unwilling or unqualified to undergo TJA
• Tramadol is conditionally recommended over other opioids for hand and/or hip OA
• 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
    • Potential for addiction should be discussed with the patient

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 OAdrug  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 OA 
    • Crystalline Glucosamine sulfate formulation has been shown to consistently improve pain and function in patients with knee OA
    • Glucosamine/Chondroitin combination may have variable pharmaceutical quality but some trials have shown efficacy in patients with knee OA
  • Chondroitin sulfate is conditionally recommended in hand OA

• 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 OA was observed
  • Associated with gastrointestinal-related adverse events

• 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 OA

Intra-articular Injections

• Indicated only if non-pharmacological therapy and systemic therapies have failed or are contraindicated

Corticosteroids

• Indicated for fast and short-term (2-4 weeks) relief of pain and swelling of joints
• Strongly recommended for patients with knee (with effusion or synovitis) and/or hip (ultrasound-guided) OA, conditionally recommended for hand OA
• Synovial fluid is first 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
• Should not administered >3-4 injections in the same joint per 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
  • Joint homeostasis is re-established through endogenous production of hyaluronic acid
• Currently indicated as a viscoelastic supplementation
• Conditionally recommended for the treatment of knee OA without effusion but not recommended for hip or polyarticular OA 
  • Associated with pain improvement at and beyond 12 weeks and showed a favorable long-term safety profile

Investigational Approaches

• Intra-articular platelet-rich plasma (PRP) injection in patients with knee OA is currently being studied, with promising results

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 OA 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 OA 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 OA
• Guidelines have strongly recommended (with compelling evidence of efficacy and that benefits clearly outweighed harms and burdens) strengthening, walking, neuromuscular training and aquatic exercises for patients with OA of the knee and hip; balance exercises and yoga are conditionally recommended (quality of the evidence proved low or very low and shared decision-making approach is vital)
• Land and aquatic exercises are both recommended for patients with symptomatic knee and hip OA     
  • The choice between land and aquatic exercises depend on the patient’s preference and ability
  • Aquatic exercises are preferred for patients with hip OA because of lesser stress to the joints due to buoyancy
• Several studies have shown pain and function improvement in patients practicing tai chi or yoga

Weight Reduction

• Patients with symptomatic OA, 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
• May help reduce the cumulative load to the lower extremity joints

Physical Therapy

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

Thermotherapy

• Adjunctive treatment conditionally recommended for hand, knee and/or hip OA
• Involves local application of heat or cold to manage symptoms of OA of the hand, knee and hip
• Cold therapy is most effective during acute flare of OA 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 wax bath is conditionally recommended for hand OA
    • Affected hand is completely dipped in the melted paraffin and removed repeatedly until coated in wax, covered with a plastic bag, then wrapped in a hand towel for 10-15 minutes

Mechanical Interventions

Assist Devices

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

Hand Orthosis

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

Knee Braces

• Maintain the joint in a fixed position and alter loading pattern to minimize joint load
• May be used to improve function, pain and quality of life in patients with knee OA
• 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 OA while a patellofemoral (PF) brace is conditionally recommended for PF OA

Taping

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

Walking Aids

• A cane is strongly recommended for patients with knee and/or hip OA 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 OA
• Medially-wedged insoles - conditionally recommended for patients with lateral compartment OA
• Based on clinical trials, there are no clinical benefits found on the use of lateral wedge insoles as a treatment for pain in medial knee OA

Alternative Therapy

Acupuncture

• Conditionally recommended for hand, knee and/or hip OA
• 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 OA patients with chronic moderate to severe pain who are unwilling or not qualified for knee arthroplasty

Cognitive Behavioral Therapy (CBT)

• Conditionally recommended for hand, knee and/or hip OA as there is limited evidence that suggests CBT may decrease OA pain

Extracorporeal Shockwave Therapy

• May be considered as an adjunctive treatment to improve pain and function in patients with knee OA

Laser Treatment

• United States Food and Drug Administration (US FDA)-approved laser treatment may be considered as an adjunctive treatment to improve pain and function in patients with knee OA; also being utilized in Asian countries (eg China, India, Malaysia, Philippines)
• Utilizes nonthermal laser light to produce therapeutic photobiomodulatory effects such as decreased inflammation, increased pain tolerance and tissue healing
• May be considered in conjunction with other treatment modalities (eg acupuncture, exercise)
• Application varies based on several factors, including wavelength, energy density, power output, and radiation duration

Manual Therapy

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

Percutaneous Electrical Nerve Stimulation (PENS)/Pulsed Electromagnetic Field (PEMF) Therapy

• PENS may be considered as an adjunctive treatment to improve pain and function in patients with knee OA
  • Minimally invasive intervention which involves insertion of very thin needles
• PEMF devices are safe which may be used to reduce pain and inflammation in patients with knee OA

Radiofrequency Ablation

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

Transcutaneous Electrical Nerve Stimulation (TENS)

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