Symptomatic management of osteoarthritis

There is currently no treatment that can reverse joint damage due to osteoarthritis, but early management can slow disease progress, and allow patients to gain control of symptoms.

Symptomatic management should be guided by the severity of the disease, the joints affected, specific symptoms, co-morbidities and activity level. A team approach to management including occupational therapist, physiotherapist and other health workers is often beneficial. Referral to a rheumatology or rehabilitation unit may be appropriate.

Paracetamol

Regular paracetamol at a dose of up to 4g per day is effective as initial oral analgesia for treating mild to moderate pain associated with osteoarthritis.² If pain is successfully managed, paracetamol can be maintained long-term.²

Topical NSAIDs

Topical NSAIDs are generally less effective than oral NSAIDs but they are considered to be safer and serious adverse effects are unlikely. Local reactions such as itching or burning may occur.² The “placebo effect” is said to play a role in the clinical effect of topical NSAIDs and they may only be effective in the first few weeks of treatment.² Topical NSAIDs can be considered, but are not a key component of treatment for osteoarthritis.

Capsaicin cream

Topical capsaicin cream (0.025%) contains a chilli pepper extract and may cause burning pain at the site of application but is an effective analgesic. Other than the intended burning effect, capsaicin is not associated with other adverse effects.²

Capsaicin cream is applied by squeezing a bead of cream onto the finger and rubbing over each affected joint, four times per day. It should not be applied after a hot bath or shower or to broken skin. Hands should be washed after application to avoid inadvertent transfer to the eyes. Treatment should be continued for three months before assessing clinical effect.

Note that topical NSAIDs and capsaicin are not subsidised for the treatment of osteoarthritis in New Zealand.

NSAIDs

There is evidence that NSAIDs are superior to paracetamol for pain relief in patients with osteoarthritis,³ but they are also associated with more adverse effects. The major concern is serious gastrointestinal, renal and cardiovascular complications, with risk increasing with age, concurrent use of other medications and duration of therapy.² NSAIDs help relieve pain, swelling and stiffness but they do not alter the progression of osteoarthritis.

Table 1: Recommended total daily doses of NSAIDs for osteoarthritis⁴

Oral NSAIDs should only be considered when paracetamol or topical treatments are ineffective for pain relief. NSAIDs should be used at the lowest effective dose for the shortest possible time. Do not exceed maximum daily doses (Table 1). Long-term use of NSAIDs is not routinely recommended,² however individual patient factors can be taken into account, such as risk of adverse events and the effect of NSAID treatment on functional ability. Paracetamol can be continued throughout NSAID treatment,¹ however topical NSAIDs should be discontinued.

Cyclo-oxygenase-2 (COX-2) selective drugs are not recommended for routine use in osteoarthritis, except where the patient is at high risk of developing a serious GI adverse effect from other standard NSAIDs, or has GI intolerance of standard NSAIDs in spite of the use of a gastroprotective agent. COX-2 drugs are not subsidised in New Zealand.

Which NSAID?

Choice of NSAID should be based on the overall safety profile of the drug and the patient’s individual risk factors. All NSAIDs have similar analgesic effect but individual patients may have a better response to one type over another. It may be reasonable to trial ibuprofen, naproxen and diclofenac depending on other risk factors. NSAIDs (including COX-2) should not be combined.²

All NSAIDs should be used with caution in patients with cardiovascular risk factors (e.g. hypertension, hyperlipidaemia, diabetes, smoking, peripheral arterial disease).² COX-2 drugs are contraindicated in patients with ischaemic heart disease or stroke.²

Naproxen 500mg, twice per day appears to be the safest choice of NSAID for patients with cardiovascular risk factors.⁵

All NSAIDs can increase blood pressure, especially in people with hypertension, and cause fluid retention and oedema. In rare cases, congestive heart failure and renal dysfunction may occur.⁵ Monitoring of blood pressure and for signs of fluid retention should occur within two to four weeks of initiating NSAID treatment.⁵

In patients with increased GI risk, prescribe a non-selective NSAID with a 20mg proton pump inhibitor (PPI) or a COX-2 selective agent.² The GI protection associated with the use of a COX-2 drug is mostly lost when low-dose aspirin is concurrently administered.² Aspirin also does not offset the increased cardiovascular risk associated with COX-2 drugs.

Opioids may be considered when other oral treatment is unsuccessful

Weak opioids such as codeine can be considered for relieving pain where other pharmacological agents have been ineffective or are contraindicated. A recommended dose of codeine is one to two 30mg tablets, every four to six hours as required, to a maximum of 240 mg (60mg codeine is equivalent to 6mg morphine).⁴

Stronger opioids should only be used for severe pain in exceptional circumstances. Adverse effects including sedation, risk of falls and constipation are common and are of particular concern in older people.

Tramadol has no advantages over other opioids but is increasingly used for pain management (50mg tramadol is equivalent to 10mg morphine). A systematic review concluded that while tramadol is effective in relieving pain and improving function in people with osteoarthritis (compared to placebo) the benefits are small. Adverse effects may limit its use and include nausea, confusion and interaction with SSRIs.⁶

Intra-articular injections may be useful in severe pain

Intra-articular injections with corticosteroids can be considered when patients have moderate to severe pain that does not respond adequately to oral treatment and when there are physical signs of local inflammation or joint effusion.^{1, 2}

Correct placement of the injection is crucial to maximise benefit and reduce the risk of adverse effects such as fat necrosis and peri-articular tissue atrophy. It is recommended that injections are administered no more than four times a year to the same joint without specialist review.² Duration of symptomatic benefit varies between individuals.

Hyaluronic acid is a glycosaminoglycan which is a constituent of synovial fluid. Hyaluranate preparations are available in New Zealand but are not subsidised and are very costly. UK guidelines do not recommend hyaluronate injections due to their high cost in relation to their benefit.¹ However, intra-articular hyaluronate injections can decrease pain and compared to corticosteroids, have a prolonged duration of symptomatic benefit (up to six months) but a delayed onset of action.²

Surgical options

Patients who cannot obtain adequate pain relief and functional improvement from core treatments and are requiring strong opioids should be considered for joint replacement surgery.² Patient specific factors such as age, gender, smoking, obesity and comorbidities should not be barriers to referral for surgery.¹

Osteotomy and joint preserving surgical procedures can be considered in younger adults, to delay the need for joint replacement.²

Joint fusion may be used as first line surgical management of joints such as first metatarsophalangeal joints, subtalar and radiocarpal joints. Joint fusion can also be considered when joint replacement has failed.²

Joint lavage and arthroscopic debridement (removal of cartilage fragments and debris) are not always associated with a significant improvement in symptoms or mobility but may reduce locking.² This procedure is not routinely recommended.¹