Section 4 - Management of diagnosed conditions

Osteoarthritis

High risk groups ^1,2

Females
Overweight or obesity
Previous joint injury, trauma or misalignment
Family history of osteoarthritis (OA)
Repetitive occupational joint loading stress
Aged

Referral

Refer to:
- physiotherapist, occupational therapist or exercise physiologist for exercise plan, home supports and falls prevention measures
- pain specialist for uncontrolled pain
- orthopaedic surgeon if unresponsive to all interventions

1. What is osteoarthritis? ^1–5

A chronic joint condition characterised by the breakdown of cartilage which results in inflammation, pain and disability
Affects the joint, cartilage, bone, synovial lining and synovial fluid, most commonly in the hands, cervical and lumbar spine, and hips and knees
Causes pain, stiffness, swelling, joint instability and muscle weakness, which impacts physical function and mobility and reduces quality of life
Prevalence increases with age affecting over 50% of those > 65 years

2. Diagnosis of osteoarthritis ^1–4

Usually based on patient history, presence of risk factors, and examination, including assessment of:
- weight, BMI and waist circumference
- muscle strength
- joint alignment and function and
- gait
Features suggestive of OA include:
- > 45 years of age and
- activity-related joint pain and
- +/- early morning joint stiffness lasting < 30 minutes
Consider investigations to exclude alternative diagnoses include:
- C-Reactive Protein (CRP)
- erythrocyte sedimentation rate (ESR)
- rheumatoid factor (RhF)
- synovial fluid analysis
- radiograph imaging
- Anti–cyclic citrullinated peptide (anti-CCP)

3. Management of osteoarthritis ^1,2,4,5

The goals of managing OA are to intervene early to slow progression, relieve pain, minimise disability and postpone or avoid surgery by:
- early recognition and control of pain symptoms
- optimising and maintaining function, quality of life and ability to perform daily activities
- identifying and addressing comorbid conditions including:
  - Dementia
  - Overweight and obesity (adult)
  - Hypertension
  - Diabetes
  - Depression
- support from a multidisciplinary team

Support patient self-management ^1–3
- Provide the patient with OA resources to maximise independent living. See Resource 1.
- Discussions should avoid terms such as ‘bone on bone’, ‘normal wear and tear’ and ‘cartilage erosion’ and involve:
  - OA progression
  - the fluctuation of symptoms
  - modifiable risk factors
  - choices and expectations of treatment
  - managing symptoms
- Utilise community support services to enhance safety, reduce risk, and support the patient to stay in their own home. See Resources 2. and 3.
- Encourage the patient to identify barriers to adequate lifestyle modification and clinical adherence and develop goals to overcome those barriers. See Engaging our patients
Social-emotional support ^1,2,4,5
- Up to 50% of those with OA will develop Depression and Anxiety disorders due to fatigue, insomnia, mood changes and pain. See Resource 4.
- See Social-emotional wellbeing
Pain control ^1–3,5,6
- Non-pharmacological interventions should be applied first and include:
  - Diet and nutrition
  - Physical activity and sleep
  - topical hot or cold pack application
  - complementary therapies may help some patients
  - walking aids
  - massage and manual therapy
  - transcutaneous electrical nerve stimulation (TENS)
  - joint taping and bracing
- Continue non-pharmacological interventions if initiating medicines as stepped approach. See Figure 1.
- Consider referral to pain specialist if Persistent pain, causes severe ongoing disability, despite multiple treatment modalities
Physical activity ^1–6
- Regular Physical activity and sleep reduces pain and increases function and quality of life with OA
- Discomfort in the affected joint(s) during exercise does not indicate disease progression
- Use supportive language such as ‘hurt does not mean harm’ and ‘sore but safe’
- Consider topical or oral analgesia prior to exercise
- Falls risk increases when exercising in combination with medicine use
- Strength and balance activities maintain muscle tone and prevents falls
- Refer to a physiotherapist or exercise physiologist to tailor and initiate an exercise regimen and strength and balance group
Weight control ^1,2,4–6
- Overweight and obesity (adult) is a risk factor for knee and hip OA due to increased joint load
- Weight loss improves gait speed and reduces knee pain
- 25–50% of knee replacements can be avoided by maintaining a healthy BMI and waist circumference or > 5% weight reduction
- See Diet and nutrition
Falls prevention ^1–3
- Screen for individual falls risk. See Resource 4.
- Optimise supportive shoe wear
- Address any hearing and vision impairments. See Ears and hearing (adult) and Eyes and vision (adult)
- Review medicines and minimise sedatives especially benzodiazepines
- Refer to a physiotherapist for a balance and strength or falls prevention group
- Refer to an occupational therapist to assess for home modifications or mobility aids e.g. walking aids, handrails, removal of slip and trip hazards
- Consider bone mineral density (BMD) testing and Osteoporosis treatment for individuals with recurrent falls
Assistive devices ^1–6
- Refer to a physiotherapist and occupational therapist for joint protection supports to minimise symptoms when performing daily activities for example:
  - tap and jar turners, adaptive eating utensils
  - splints or braces to support joints
  - application of heat or ice
  - zipper pulls and buttoning aids for clothing
  - raised over toilet seats
  - see Resource 5.
Surgery ^1,2,4,5

Around 30% of OA will progress to a severity requiring surgery e.g. knee, spine
Refer to an orthopaedic surgeon where debilitating pain or dysfunction persists despite optimal lifestyle modification and clinical interventions

4. Medicines for osteoarthritis

General principles ^1–6
- Medicines aim to improve function and quality of life by managing acute or persistent pain and stiffness despite optimal non-pharmacological management interventions
- Medicines are trialled in relation to the patient’s symptoms with the aim to control pain at the lowest effective dose and shortest possible time
- Opioids are not recommended as risks outweigh the benefits e.g. falls
- If on NSAIDs check eGFR, ACR, FBC and LFTs annually
- For further pain relief options see Persistent pain
Topical agents ^1–4
- Offer a topical NSAID 2–4 times daily for up to 14 days then review for efficacy. If ineffective offer oral. See Table 1.
- Consider other topical creams, ointments, gels, liniments and sprays including:
  - counter-irritants that provide a sensation of warmth e.g. eucalyptus oil, turpentine oil, nicotinate, nonivamide, salicylates and camphor
  - agents that produce a feeling of coolness e.g. menthol
  - capsaicin which acts as an analgesic causing a stinging or burning sensation
- Rare side effects include irritation, itching, erythema, rash or dermatitis (chemical burns), bronchospasm or dyspnoea (salicylates), nausea or photo-sensitivity

Table 1. Medicines for osteoarthritis ^1,3,4,5,6,7
Table 1. Medicines for osteoarthritis ^1,3–7
NSAIDs Avoid in those with increased cardiovascular disease risk, eGFR < 30 mL/min Adverse effects include HF, GI ulceration and renal impairment especially in elderly If risk of upper GI bleeding risk begin proton-pump inhibitor (PPI) Contraindicated in active peptic ulcer disease or GI bleeding. where appropriate Efficacy is similar for different NSAIDs for the treatment of osteoarthritis Addition of paracetamol may produce additive benefit and a reduced NSAID dose
Ibuprofen 200–400 mg PO tds (to a max. 2400 mg daily) OR Ketoprofen MR 200 mg PO daily OR Naproxen 250–500 mg PO bd (to a max. 1250 mg daily)
Paracetamol Consider short trial for knee or hip OA if other medicines are contraindicated, not tolerated or ineffective. Discontinue if ineffective
Paracetamol 1 g PO 4–6 hrly prn (to max. 4 g daily) OR Paracetamol MR 1.33 g PO tds prn
Duloxetine Consider for persistent knee pain
*Duloxetine 30 mg PO daily for 1 week, increasing to 60 mg daily (to max. 120 mg)
*See LAM and PBS for medicine indications and restrictions

Table 1. Medicines for osteoarthritis ^1,3,4,5,6,7

Table 1. Medicines for osteoarthritis ^1,3–7

NSAIDs

Avoid in those with increased cardiovascular disease risk, eGFR < 30 mL/min
Adverse effects include HF, GI ulceration and renal impairment especially in elderly If risk of upper GI bleeding risk begin proton-pump inhibitor (PPI)
Contraindicated in active peptic ulcer disease or GI bleeding. where appropriate
Efficacy is similar for different NSAIDs for the treatment of osteoarthritis
Addition of paracetamol may produce additive benefit and a reduced NSAID dose

Ibuprofen 200–400 mg PO tds (to a max. 2400 mg daily) OR

Ketoprofen MR 200 mg PO daily OR

Naproxen 250–500 mg PO bd (to a max. 1250 mg daily)

Paracetamol

Consider short trial for knee or hip OA if other medicines are contraindicated, not tolerated or ineffective. Discontinue if ineffective

Paracetamol 1 g PO 4–6 hrly prn (to max. 4 g daily) OR

Paracetamol MR 1.33 g PO tds prn

Duloxetine

Consider for persistent knee pain

*Duloxetine 30 mg PO daily for 1 week, increasing to 60 mg daily (to max. 120 mg)

*See LAM and PBS for medicine indications and restrictions

Intra-articular corticosteroid injections ^1,3–7

Only considered for acute pain if simple analgesia ineffective, contraindicated or not tolerated. See Table 2. for corticosteroid choice

Table 2. Intra-articular corticosteroid injections for OA ^1–3,7
Local corticosteroid injections Give no more then 4 injections/year to avoid local tissue atrophy or side effects Avoid further injections if no response after 2 consecutive injections Patients to avoid overusing joint following injection as this risks further joint deterioration and reduces beneficial effects Local anaesthetic may be used before, or mixed with the corticosteroid Not given if evidence of skin, joint or soft tissue infection at the injection site
Preparation	Small joint (e.g. hand)	Medium joint (e.g. wrist)	Large joint (e.g. knee)	Soft tissue (e.g. bursa)
Betamethasone sodium phosphate + betamethasone acetate 5.7 mg/mL	0.25–0.5 mL	0.5–1 mL	1–2 mL	1 mL
Methylprednisolone acetate 40 mg/mL	0.1–0.25 mL	0.25–1 mL	0.5–2 mL	0.1–0.75 mL
Triamcinolone acetonide 10 mg/mL	0.25–1 mL	1 mL	0.5–2 mL	1–2 mL
Triamcinolone acetonide 40 mg/mL	0.1–0.25 mL	0.25 mL	0.5–1 mL	0.5 mL

5. Cycle of care

Cycle of care summary for osteoarthritis
Action	Dx	Frequency
Height		Once
Weight		12 mthly
BMI		12 mthly
Waist circumference		12 mthly
BP		12 mthly
FBCs, LFTs, eGFR and ACR		Annually if on NSAIDs
Smoking cessation		Each visit
Physical activity		Each visit
Diet and nutrition		Each visit
Carer education and support		Each visit
Social-emotional wellbeing		Each visit
Influenza, pneumococcal and COVID-19 vaccines	Recommended. See the Australian Immunisation Handbookfor schedule
Lifestyle modification		Each visit
Medicine review		If on NSAIDs then 3–6 mthly initially then annually
HW/RN review		6 mthly
MO/NP review		6 mthly
Occupational therapist		As required
Physiotherapist		As required
Specialist review		As required
Falls risk assessment		As patient situation changes
Balance and strength exercise program		As determined by physiotherapist

6. References

All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

Last updated: September 2024