Assessment and Management of Knee Osteoarthritis

Diagnosis and Pre-Treatment Screening

The American College of Rheumatology recommends confirming the diagnosis of knee osteoarthritis through radiographic evidence of joint space narrowing, osteophytes, or subchondral sclerosis 1
Patients with a history of peptic ulcer disease, GI bleeding, GERD, or age ≥75 years are at increased risk for gastrointestinal complications and should be screened before initiating diclofenac 1
The American Heart Association recommends assessing cardiovascular status, including current use of low-dose aspirin for cardioprotection and history of cardiovascular disease, before initiating diclofenac 1
The National Kidney Foundation recommends assessing renal function, including estimated glomerular filtration rate (eGFR), before initiating diclofenac, as oral NSAIDs are contraindicated if eGFR <30 mL/min 1
The American Geriatrics Society recommends documenting all concurrent medications, including acetaminophen-containing products, to avoid exceeding 4,000 mg/day total 1

For patients ≥75 years old, the American Geriatrics Society recommends using topical diclofenac gel 4g four times daily rather than oral formulation due to substantially greater risk for cardiovascular, gastrointestinal, and renal adverse reactions 2
The American College of Rheumatology recommends using a COX-2 selective inhibitor or nonselective NSAID (diclofenac) combined with a proton-pump inhibitor for patients with a history of symptomatic or complicated upper GI ulcer 1
For patients taking low-dose aspirin (≤325 mg/day) for cardioprotection, the American Heart Association recommends avoiding ibuprofen due to pharmacodynamic interaction that renders aspirin less effective 1 2
The American College of Rheumatology recommends strongly adding a proton-pump inhibitor when combining diclofenac with aspirin 1

The American Academy of Orthopaedic Surgeons recommends considering intraarticular corticosteroid injections if diclofenac fails after 4 weeks 1
The American Pain Society recommends adding tramadol, duloxetine, or intraarticular hyaluronan injections if diclofenac fails after 4 weeks 1
The American Academy of Orthopaedic Surgeons recommends referring for consideration of total joint arthroplasty if refractory to both nonpharmacologic and pharmacologic modalities 1

The National Institutes of Health recommends avoiding chondroitin sulfate or glucosamine as they lack efficacy 1