Treatment: Osteoarthritis

• Treatment goal—alleviate pain and minimize loss of physical function.
• Nonpharmacotherapy strategies aimed at altering loading across the painful joint—include pt education, weight reduction, appropriate use of cane and other supports, isometric exercises to strengthen muscles around affected joints, bracing/orthotics to correct malalignment.
• Topical capsaicin cream may help relieve hand or knee pain.
• Acetaminophen—commonly used analgesic, caution regarding hepatic toxicity.
• NSAIDs, COX-2 inhibitors—GI, renal, cardiovascular toxicity, must weigh individual risks and benefits.
• Topical NSAIDs—fewer GI and systemic side effects; can cause skin irritation
• Opioid analgesics—may be considered in selected pts whose symptoms are inadequately controlled with other measures and who cannot undergo surgery; habituation is a potential concern.
• Intraarticular glucocorticoids—may provide symptomatic relief but typically short-lived.
• Intraarticular hyaluronan—can be given for symptomatic knee and hip OA, but it is controversial whether it has efficacy beyond placebo.
• Glucosamine and chondroitin—large scale trials have failed to show efficacy for pain relief; recent guidelines recommend against use.
• Systemic glucocorticoids have no place in the treatment of OA.
• Arthroscopic debridement and lavage—randomized trials have shown no greater effect on pain relief or disability compared to sham procedure or no treatment.
• Joint replacement surgery may be considered in pts with advanced OA who have intractable pain and loss of function in whom aggressive medical management has failed.

For a more detailed discussion, see Felson DT: Osteoarthritis, Chap. 394, p. 2226, in HPIM-19.