eMedicine Specialties > Rheumatology > Osteoarthritis
Osteoarthritis: Treatment & Medication
Updated: Apr 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Nonpharmacologic interventions are the cornerstones of osteoarthritis (OA) therapy and include patient education, temperature modalities, weight loss,1 exercise, physical therapy, occupational therapy, and joint unloading in certain joints (eg, knee, hip).
- Reduction of joint stress
- Instruct the patient to avoid aggravating stress to the affected joint.
- Implement correction procedures if the patient illustrates poor posture.
- Encourage obese patients to lose weight, thus relieving stress on the affected knees or hips.
- Occupational adjustments may be necessary.
- Physical therapy
- Osteoarthritis of the knee may result in disuse atrophy of the quadriceps. These muscles help protect the articular cartilage from further stress.
- Instruct the patient to perform aerobic and muscle-strengthening exercises.
- Chaipinyo and Karoonsupcharoen (2009) found no significant difference between home-based strength training and home-based balance training for knee pain caused by osteoarthritis. However, more improvement was noted in the strength group in terms of knee-related quality of life (improved 17 points out of 100 [95% CI, 5-28] more than the balance group).2
- Hydrotherapy may be beneficial.
- Some patients with osteoarthritis benefit from heat and capsaicin cream placed locally over the affected joint, and a minority of patients report relief with ice.3
- Pharmacologic therapy
- The goals of osteoarthritis treatment include pain alleviation and improvement of functional status. Presently, no practical medication-based disease or structure-modifying intervention has been proven.
- Begin treatment with acetaminophen for mild or moderate pain without apparent inflammation.
- If the clinical response to acetaminophen is not satisfactory or if the clinical presentation is inflammatory, consider nonsteroidal anti-inflammatory drug (NSAIDs). Use the lowest effective dose or intermittent dosing if symptoms are intermittent and then try full doses if the patient's response is insufficient.
- Options in patients at an elevated risk for GI toxicity due to NSAIDs include the addition of a proton-pump inhibitor or misoprostol to the treatment regimen or the use of a selective cyclooxygenase inhibitor instead of the nonselective NSAID.
- In patients with highly resistant pain, consider the analgesic tramadol.
- Muscle relaxants may benefit patients with evidence of muscle spasm.
- Contemplate intra-articular injections of glucocorticoids to improve symptoms. No more than 4 glucocorticoid injections should be administered to a single joint per year because of the risk of long-term damage to cartilage. Systemic glucocorticoids have no role in the management of osteoarthritis. Intra-articular injections of hyaluronic acid (HA) are approved as symptomatic therapy of osteoarthritis in the knee. Prescribe as a series of 3 or 5 injections (depending on the product). Each injection is administered one week apart.
- Judicious use of narcotics (eg, acetaminophen with codeine) is reserved for patients with severe osteoarthritis.
Surgical Care
- Joint lavage: Closed-needle joint lavage may benefit a small subgroup of patients with osteoarthritis.
- Arthroscopy: Arthroscopy may help patients with osteoarthritis of the knee that in whom imaging reveals specific structural damage (eg, for repairing meniscal tears, removing fragments of torn menisci that are producing symptoms). Overall, arthroscopy is not recommended for nonspecific "cleaning of the knee" in osteoarthritis.
- Osteotomy
- Consider this procedure in patients with a malaligned hip or knee joint.
- The procedure is usually recommended in younger patients with osteoarthritis.
- Osteotomy can lessen the pain, although it can lead to more challenging surgery later if the patient requires arthroplasty.
- Arthroplasty
- Perform this procedure if all other modalities are ineffective and osteotomy is not viable or if a patient cannot perform his or her daily activities despite maximal therapy.
- This procedure alleviates pain and may improve function. Approximately 8-15 years of viability are expected from the joint replacement in the absence of complications.
Consultations
- A physiatrist may help in formulating a nonpharmacologic management plan.
- A referral to an orthopedic surgeon may be necessary if the osteoarthritis fails to respond to a medical management plan.
- A nutritionist may help the patient lose weight.
Diet
A diet to achieve some degree of weight loss may be beneficial.
Activity
Osteoarthritis may severely hinder the patient's ability to work or even to perform daily living activities, depending on the joints involved and the degree of involvement.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Pay careful attention to a particular pharmacologic regimen's adverse-event profile.
Analgesic agents
Pain control is essential in the management of osteoarthritis (OA). The goals of treatment include pain alleviation and improvement of functional status. Currently, disease/structure-modifying intervention has been proven
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)
Initial trial warranted in patients with mild-to-moderate symptoms from osteoarthritis who fail to get sufficient relief with nonpharmacologic measures. DOC for patients with documented hypersensitivity to aspirin or NSAIDs, history of upper GI disease, or on anticoagulants.
Adult
1000 mg PO tid/qid; not to exceed 4 g/d
Pediatric
Disease state not seen in pediatrics
Rifampin may reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity can occur with various dose levels in persons with chronic alcoholism; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose/d
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents have analgesic, anti-inflammatory, and antipyretic activities. They are used for to relieve osteoarthritis pain when the clinical response is unsatisfactory to acetaminophen. The mechanism of action is nonselective inhibition of cyclooxygenases 1 and 2, resulting in reduced synthesis of prostaglandins and thromboxanes. Other mechanisms may also exist, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
In more inflammatory presentations of osteoarthritis, such as knee involvement with effusion, these agents may be used as first-line pharmacologic therapy.
Use the lowest effective dose or intermittent therapy if symptoms are intermittent.
Patients at high risk for GI toxicity may consider adding misoprostol or a proton pump inhibitor to the regimen or substituting a COX-2–specific inhibitor for the NSAID.
Ibuprofen (Ibuprin, Advil, Motrin)
Relieves pain and inflammation. Widely available. Relatively inexpensive as a generic drug.
Adult
400 mg PO tid prn; not to exceed 2400 mg/d
Pediatric
Disease state not seen in pediatrics
May decrease effects of loop diuretics; coadministration of anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity of NSAIDs
Documented hypersensitivity to ibuprofen, other NSAIDs, or aspirin; avoid in peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, decreased renal and hepatic function, anticoagulation abnormalities, or during anticoagulant therapy; adjust dose in renal insufficiency
NSAID labeling carries a warning about increased risk of hypertension, stroke, and cardiovascular events, including myocardial infarction
Meloxicam (Mobic)
To some extent, more selective for COX-2 receptors, compared to traditional NSAIDs. Decreases activity of cyclooxygenase, which in turn inhibits prostaglandin synthesis. These effects decrease formation of inflammatory mediators.
Adult
7.5 mg PO qd prn; may increase to 15 mg PO qd prn
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; active GI bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur, (discontinue if there is persistent leukopenia, granulocytopenia, or thrombocytopenia)
NSAID labeling carries a warning about increased risk of hypertension, stroke, and cardiovascular events, including myocardial infarction
COX-2 inhibitors
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is less in nonaspirin users receiving COX-2 inhibitors than with traditional NSAIDs.
Celecoxib (Celebrex)
COX-2–specific inhibitor. At therapeutic concentrations, COX-2 (inducible by cytokines at sites of inflammation such as the joints) is inhibited and COX-1 isoenzyme (present in platelets and GI tract) is spared; therefore, in nonaspirin users, incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, is decreased when compared to nonselective NSAIDs. COX-2 is expressed in the kidney; however, the renal safety profile is not significantly superior to that of NSAIDs.
Adult
100 mg PO bid or 200 mg PO qd
Pediatric
Disease state not seen in pediatrics
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity to celecoxib, sulfonamides, NSAIDs or aspirin
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in late pregnancy to avoid closure of ductus arteriosus; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention, presence of existing controlled infections, severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; evaluate symptoms suggesting liver dysfunction or in abnormal liver lab results; adjust dose in renal insufficiency
NSAID labeling carries a warning about increased risk of hypertension, stroke, and cardiovascular events, including myocardial infarction
More on Osteoarthritis |
| Overview: Osteoarthritis |
| Differential Diagnoses & Workup: Osteoarthritis |
 Treatment & Medication: Osteoarthritis |
| Follow-up: Osteoarthritis |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
osteoarthritis, osteoarthrosis, OA, knee osteoarthritis, hip osteoarthritis, spinal osteoarthritis, foot osteoarthritis, secondary osteoarthritis, secondary OA, knee OA, hip OA, spinal OA, foot OA, osteophytes, joint pain, back pain, noninflammatory arthritis, degenerative joint disease, articular disease, articular cartilage disease, bony osteophytes
