Osteoarthritis

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31/01/2024

Osteoarthritis

Osteoarthritis is a condition characterized by the deterioration of cartilage, the protective tissue at joint surfaces. It is primarily caused by joint overuse, improper joint use, or the natural aging process. Commonly affected individuals include women over the age of 50, those who are overweight, people with previous joint injuries, and those repeatedly performing joint-intensive activities (e.g., climbing stairs, prolonged knee bending, or extended periods of standing).

Commonly affected joints include the knees, lumbar and cervical spine, finger joints, and hips. The breakdown of cartilage leads to bones rubbing together during movement, causing inflammation, pain, stiffness, swelling, and reduced mobility. Without proper treatment, joint deformities and disability may occur.

Patient Advice

Prevention of Exacerbation

Weight reduction significantly decreases joint stress.
Physiotherapy and supportive equipment (e.g., knee braces or supports) may help reduce pain by absorbing impact.

Self-Management

Apply warm or cold compresses to painful joints for symptom relief.

Engage in muscle-strengthening exercises around the kneeor aerobic activities for at least 150 minutes weekly.

Avoid activities that strain or inflame joints.

Understand the disease and medication usage thoroughly for effective management.

Regular practice of Tai Chi can strengthen muscles and joints, improve balance, and reduce fall risks, especially for patients with knee or hip osteoarthritis.

Treatment Options

1. Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are widely used for relieving joint pain and swelling by inhibiting prostaglandin synthesis. Common side effects include gastrointestinal irritation or ulcers and increased risk of cardiovascular events and acute renal failure in certain patients. Therefore, their use should always be evaluated by a physician or pharmacist.

NSAID Dosage and Administration in Adults

Drug	Adult Dosage (D)	Administration (A)
Loxoprofen	60 mg three times daily or 120 mg once daily	Take with or immediately after food
Aspirin	300–900 mg every 4–6 hours (max 4,000 mg/day)	Take with or immediately after food
Mefenamic acid	250–500 mg three times daily	Take with or immediately after food
Meloxicam	7.5–15 mg once daily (max 15 mg/day)	Take with or after food if gastric irritation occurs
Diclofenac	Tab: 50 mg 2–3 times/day; DR tab: 75–100 mg/day in 2–3 doses; ER tab: 75–100 mg/day	Take with or immediately after food
Nabumetone	1,000 mg once daily; additional 500–1,000 mg in morning if needed (max 2,000 mg/day)	Take with or immediately after food to reduce gastric irritation
Etodolac	Cap: 200 mg every 6–8 hrs or 400 mg every 12 hrs (max 1,000 mg/day); ER: 400–800 mg once daily	Take with or immediately after food
Naproxen	250–500 mg twice daily	Take with or immediately after food
Fenbufen	900 mg/day (e.g. 300 mg AM, 600 mg PM)	Take with or immediately after food
Piroxicam	10–20 mg once daily (max 20 mg/day)	Take with or immediately after food
Floctafenine	200–400 mg every 6–8 hrs (max 1,200 mg/day)	Take with or immediately after food
Proglumetacin	150–300 mg twice daily (max 600 mg/day)	Take with or immediately after food
Flurbiprofen	50 mg 2–4 times/day or 100 mg twice/day (max 300 mg/day)	Take with or immediately after food
Sulindac	150–200 mg twice daily (max 400 mg/day)	Take with or immediately after food
Ibuprofen	400–800 mg 3–4 times/day (max 3,200 mg/day)	Take with or immediately after food
Tenoxicam	20 mg once daily	Take with or immediately after food
Indometacin	25 mg 2–3 times/day; may titrate weekly by 25–50 mg to max 150–200 mg/day	Take with or immediately after food
Tiaprofenic acid	200–300 mg 2–3 times/day (max 600 mg/day)	Take with or immediately after food
Ketoprofen	Cap: 100 mg twice daily (max 300 mg/day); PR cap: 100–200 mg once daily (max 200 mg/day)	Take with or immediately after food

Recommendations:

Avoid NSAIDs in patients with gastrointestinal ulcers, gastrointestinal inflammation, asthma, known allergy to NSAIDs or aspirin, history of coronary artery bypass surgery, cardiovascular diseases, renal failure, and hepatic failure.
Salicylates (e.g., aspirin): Use with caution in children due to the risk of Reye’s syndrome, a life-threatening condition.
Selective COX-2 inhibitors (e.g., celecoxib,etoricoxib) are specifically indicated for managing pain in osteoarthritis and rheumatoid arthritis.

COX-2 Selective NSAIDs Dosage and Administration

COX-2 Selective NSAIDs

Drug	Adult Dosage (D)	Administration (A)
Celecoxib	200 mg once or twice daily (maximum 400 mg/day)	May be taken on an empty stomach or after meals
Etoricoxib	30–90 mg once daily	May be taken on an empty stomach or after meals

Both NSAIDs and selective COX-2 inhibitors can increase the risk of arterial thrombosis, myocardial infarction, stroke, and gastrointestinal bleeding.
Combining pain relievers such as paracetamol with NSAIDs (e.g., ibuprofen) can enhance pain relief in osteoarthritis.
Topical NSAIDs (e.g., diclofenac, diethylamine salicylate, ibuprofen, ketoprofen, and piroxicam in cream, gel, spray, or patch form) can also be effective adjunctive treatments.

2. Non-Opioid Analgesics

Paracetamol effectively reduces mild to moderate pain associated with musculoskeletal conditions. It also has mild anti-inflammatory effects and is generally safe for regular use.

3. Opioid Analgesics

Opioids (e.g., tramadol) may be considered for moderate to severe pain or when NSAIDs cannot be used due to allergies or ineffectiveness. Usage requires close medical supervision due to risks of dependency and side effects.

4. Corticosteroids

Corticosteroids (e.g., dexamethasone, hydrocortisone, methylprednisolone, prednisolone,triamcinolone) effectively reduce severe joint inflammation, particularly during acute exacerbations or multiple joint inflammations. Typically used short-term.
They do not halt disease progression; thus, long-term use should be avoided unless necessary due to potential side effects, including hypertension, hyperglycemia, osteoporosis, glaucoma, and skin thinning.

5. Other Musculoskeletal Agents

Chondroitin: Supported by evidence for benefits in hand osteoarthritis.
Sodium hyaluronate: A polysaccharide derivative (sodium glucuronate and N-acetyl-glucosamine) administered via intra-articular injections to relieve symptoms of knee osteoarthritis./li>