Treatment of Osteoarthritis
There is no treatment to prevent the development of osteoarthritis, or cure it once it has set in. Therefore, treatment is aimed at reducing pain, minimizing joint damage, and improving or maintaining function and quality of life.
The American College of Rheumatology (ACR) recently revised its recommendations for treatment of osteoarthritis (OA) of the hand, hip, and knee.1 According to the ACR, the treatment of arthritis should include the following:
- Nonpharmacologic therapies
- Physical or occupational therapy
- Splints or joint assistive aids
- Patient education and support
- Weight loss
Figure 1 illustrates the 6 types of interventions that should be considered for the treatment of OA. It is important for patients to realize that most of these treatments have a small to moderate impact on OA pain. Because no single modality provides complete relief of symptoms, use of multiple modalities to treat OA is recommended.2 Combining multiple modalities allows for synergy among the different treatments and often provides better pain relief.
In considering other treatment options, we have made recommendations based on the best evidence available to date. Most of the studies that have been conducted have been performed in knee OA or a mixed group of patients with knee or hip OA.
Medications—whether prescription or over-the-counter (OTC)—can make OA more manageable. Table 1 reviews the ACR recommendations for medication indications for knee and hip OA.3,4 OTC medications typically are the first line of treatment, whereas prescription medications are reserved for more severe pain.
Acetaminophen: Before recommending any other medication, many physicians start patients on a trial of acetaminophen (Tylenol, others). It is typically considered a safe and effective medication for OA. Acetaminophen can help relieve mild to moderate OA pain. However, to avoid rare but serious adverse effects (AEs) of kidney and/or liver damage, patients must follow dosing instructions and avoid drinking excessive amounts of alcohol while taking acetaminophen.
Non-steroidal anti-inflammatory drugs (NSAIDs): OTC NSAIDs, such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve, others), are among the most commonly used to treat OA of all joints. Prescription-strength NSAIDs are the most common prescription medications used to treat OA. To avoid unwelcome AEs on the heart, stomach, intestines, and kidneys from NSAIDs, patients should take these medications exactly as directed.
COX-2 Inhibitors: Cyclooxygenase (COX)-2 inhibitors are the newest class of prescription-strength NSAIDs. COX-2 inhibitors help reduce pain and inflammation as effectively as traditional NSAIDs, but they are believed to carry fewer risks for gastroinestinal (GI) problems. Celecoxib (Celebrex, others) is the only COX-2 inhibitor currently on the market in the US.
Corticosteroids: Corticosteroids are powerful anti-inflammatory agents that can be taken by mouth or injected directly into the joint. They work by helping to temporarily reduce pain and inflammation in the joint. The effects of the corticosteroids may not last very long, and patients typically cannot have more than 4 injections in each joint per year. Also, over time, corticosteroids can become less effective as arthritis worsens. For patients with spinal OA, 2 types of injections are commonly performed: epidural steroid injection and facet joint injection. These injections may provide short-term pain relief.
Hyaluronic acid (HA) substitutes: Also known as viscosupplements, HA substitutes help reduce pain and swelling by lubricating joints and restoring the healthy joint fluid that typically diminishes with OA. Currently approved only for knee OA, HA substitutes usually are given in a series of 3 to 5 injections. A single-injection formula that offers up to 6 months of pain relief also is available.
Opioids: These agents generally are reserved for the management of moderate to severe pain caused by OA. Hydrocodone and acetaminophen (Vicodin, others) is the most commonly prescribed opioid in the United States. Tramadol (Ultram, others) is a less potent pain reliever for knee OA if more powerful opioids want to be avoided.
Topical pain-relieving creams, rubs, and sprays: These can be used along with or instead of oral medications. Patients older than 75 years of age may be advised to use topical NSAIDs applied to the skin instead of oral doses because they are thought to cause less GI bleeding and fewer additional AEs. Voltaren Gel is a topical prescription formulation of the NSAID diclofenac that is approved to treat knee OA. Capsaicin skin cream, derived from chili peppers, also may relieve pain.
While OA can’t be cured, it is possible to slow down its progression. In addition to medications, some treatments also help patients manage their symptoms and maintain a good quality of life. Table 2 reviews the ACR recommendations for nonpharmaceutical management of hip and knee OA. Table 3 outlines other potential treatment options.
Physical therapy (PT): A physical therapist can help patients maintain mobility, teach them how to reduce pain, and give them exercises that will strengthen their core muscles. PT may help increase flexibility and range of motion, and strengthen the muscles in the hip and leg. A physical therapist can help patients develop an exercise plan that works for their life and teach them how to move in ways that don’t increase pain.
Low-impact exercise (swimming or biking, for example) can help strengthen muscles that support the joints, which can reduce pain. Exercise also can increase flexibility, which is something that is gradually lost with OA.
Patients with mild cases of hip OA should be encouraged to protect the hip joint, to slow the progress of OA, for example, by limiting any activities that may cause pain, such as climbing stairs. If a patient is an avid golfer, skier, hiker, or runner, clinicians should recommend they consider switching to more low-impact activities, such as cycling, swimming, and weight training.
Although it may sound painful to patients, exercise can help improve the range of motion in the knees of OA patients. (See Exercise to Manage Knee Osteoarthritis)
If a patient is experiencing a painful flare-up, recommend the rest for a day or so may help. However, patients should be discouraged from remaining inactive for too long because joints can become more painful.