Components of management for osteoarthritis

Bannuru, 2019Bennell, 2012Fernandes, 2013Kloppenburg, 2019Kolasinski, 2020The Royal Australian College of General Practitioners (RACGP), 2018

Osteoarthritis is best managed with an integrated chronic disease model of care that supports multidisciplinary involvement and is underpinned by a biopsychosocial approach. The general practitioner is usually the care coordinator. Based on the patient’s needs, other members of the multidisciplinary team may include a physiotherapist, an exercise physiologist, a dietitian, a psychologist, a nurse, an occupational therapist, a rheumatologist and an orthopaedic surgeon.

The majority of patients with osteoarthritis have at least one comorbid condition, including other rheumatological diagnoses. Patients with osteoarthritis are more likely than their age- and gender-matched peers to have hypertension, diabetes, depression and obesity. Comorbidities such as hypertension, gastro-oesophageal reflux disease and obesity can impact, and be impacted by, osteoarthritis and its management. Therefore, optimising the management of comorbidities should be considered in every osteoarthritis management plan.

Note: Optimising the management of comorbidities should be considered in every osteoarthritis management plan.
The essential features of osteoarthritis management are summarised in Essential features of osteoarthritis management. Although not an exhaustive list, it should be considered the minimum standard of care for all patients. Importantly, the risk of harms should be taken into account in the decision to initiate management strategies.

The evidence base for intervention in osteoarthritis largely comprises clinical trials in patients with knee osteoarthritis. A smaller number of trials have been performed for osteoarthritis of the hip and hand and very few for spinal osteoarthritis, in part because of the difficulties in defining the patient population. While there are specific considerations in the management of osteoarthritis at different joints, the essential features of management apply to osteoarthritis at any joint. For specific considerations in the management of hand osteoarthritis, see Osteoarthritis of the hand.

Figure 1. Essential features of osteoarthritis management.

[NB1] [NB2]

  • Individualise the goals of management and the management plan (including a ‘bad day’ management plan) through shared decision making, taking into account the patient’s affected joints, the stage and severity of their disease, their functional impairments, their risk factors for disease progression, and their age, comorbidities and concomitant treatments.
  • Discuss and provide reassurance about the nature of the condition with the patient and provide support for self-management (see Shared decision making and self-management of osteoarthritis).
  • Optimise the management of comorbidities, including other rheumatological diagnoses.
  • If the patient is overweight or has obesity, provide advice about weight loss and refer to services as required.
  • Provide advice about exercise and refer to services as required.
  • Provide advice about other nonpharmacological interventions (see Physical treatments for osteoarthritis and Psychological therapies for osteoarthritis).
  • If topical analgesia is needed, trial a topical NSAID or capsaicin.
  • If oral analgesia is needed, both paracetamol and oral NSAIDs have a role (see Oral paracetamol and NSAIDs for osteoarthritis for further discussion).
  • Organise regular clinical review to monitor progress towards the patient’s goals and modify goals and the management plan as needed. If there are concerns about the patient’s progress, consider specialist referral.
  • Following an adequate trial period, assess interventions against management goals:
    • stop unhelpful or harmful treatments
    • optimise oral analgesia to enable physical function, rather than to abolish pain
    • osteoarthritis symptoms can fluctuate; if symptoms improve, trial tapering and stopping oral analgesics.
Note:

NSAIDs = nonsteroidal anti-inflammatory drugs

NB1: See also the Australian Commission on Safety and Quality in Health Care (ACSQHC) Osteoarthritis of the Knee Clinical Care Standard.

NB2: This is not an exhaustive list but should be considered the minimum standard of care for all patients.

For patients with persisting functional impairment and pain despite implementing the strategies in Essential features of osteoarthritis management, a trial of other interventions may be considered depending on the affected joints, and the stage and severity of disease. These include intra-articular corticosteroid injections and duloxetine. Therapies for central sensitisation may be considered for patients with more widespread nonspecific pain (see Management for fibromyalgia for drugs that may be appropriate for central sensitisation). Options for end-stage disease include surgery and opioids. In all cases patients should be encouraged to maintain lifestyle measures such as exercise and weight loss.
Formal osteoarthritis chronic care programs have been established in some public and private care settings. These programs use an integrated multidisciplinary approach targeted to the patient’s needs. Although these programs are evolving and not yet widely available, referral to such programs may be considered for patients who do not respond to the strategies in Essential features of osteoarthritis management, or do not have access to co-located multidisciplinary care.