Management of Knee Osteoarthritis

Pharmacological Interventions

• The American College of Physicians recommends diclofenac gel for knee osteoarthritis pain, providing effective pain relief with minimal systemic absorption 1
• Duloxetine is suggested as an alternative or adjunctive therapy when acetaminophen or NSAIDs provide inadequate response, particularly effective for chronic pain conditions 1
• Initiating opioids (including tramadol) for osteoarthritic pain is not recommended 1
• Topical diclofenac gel is the most effective topical NSAID with a favorable safety profile and should be considered first-line for localized musculoskeletal pain 2, 1
• Oral NSAIDs, such as naproxen 500 mg BID, are recommended for their superior efficacy in reducing pain while maintaining a relatively favorable cardiovascular risk profile, but should be used with caution in patients with cardiovascular risk factors or GI risk factors 3, 4, 5, 6
• The following table compares the efficacy and safety profile of different medications:

• Topical capsaicin may be considered as an alternative for localized pain, and duloxetine may be considered as adjunctive therapy 1
• Corticosteroid injection into the bursa can be considered if symptoms persist beyond 6 weeks of conservative management, and intra-articular corticosteroid injection is indicated for knee pain flares, especially when accompanied by effusion, providing effective short-term pain relief (1-2 weeks) 7, 8, 9

Non-Pharmacological Interventions

• Physical therapy is strongly recommended as part of comprehensive management, including strengthening exercises, aerobic activities, and proprioceptive exercises 1
• A self-management program including exercise and weight loss (if overweight) is recommended 1
• Bracing for knee osteoarthritis is also recommended as part of a self-management program 1
• Exercise therapy, including strengthening, aerobic, and proprioceptive exercises, is essential for optimal outcomes, and physical therapy, including land-based or aquatic exercise programs, can be beneficial for patients with knee pain 10, 11, 12, 6
• Appropriate footwear and bracing may be indicated for some patients, and pacing activities, local heat or cold applications, and assessing footwear for shock-absorbing properties are recommended as adjuncts to manage pain 6, 1, 11
• Weight loss is recommended if the patient is overweight, as part of a comprehensive management plan that combines pharmacological with non-pharmacological approaches 8, 6

Safety Considerations

• Avoid increasing NSAID dose due to increased risk of GI, renal, and cardiovascular adverse effects, especially in patients over 60 years 13
• Regular assessment of blood pressure, renal function, and GI symptoms is necessary to monitor for NSAID toxicities 13
• The American Geriatrics Society recommends using caution in elderly patients or those with a history of gastrointestinal issues, and considering gastroprotection with a proton pump inhibitor 11
• Older adults (≥60 years) are at higher risk of GI complications when using NSAIDs, and cardiovascular risk increases with age, and NSAIDs should be used with caution in older adults, with regular assessment of renal function, GI symptoms, and pain control 14, 6, 1, 15
• Topical NSAIDs are particularly suitable for older adults due to reduced risk of systemic adverse effects, and are safe in patients with hypertension, type 2 diabetes, or cardiovascular disease 2

Follow-up and Monitoring

• Short-term follow-up (1-2 weeks) is necessary to assess response to acetaminophen for pain control, evaluate resolution of constipation, and review any diagnostic imaging results, and long-term considerations include monitoring for any signs of bowel obstruction and considering referral to orthopedics or gastroenterology if symptoms persist 8, 15
• Schedule follow-up in 2 weeks to assess response to naproxen and physical therapy, and review X-ray results to guide further management, and monitor for signs of infection (fever, increasing erythema, warmth) which would necessitate a change in management approach 11, 15