What are the guidelines on pharmacologic treatment of knee osteoarthritis (OA)?

Updated: Oct 12, 2020
  • Author: Carlos J Lozada, MD; Chief Editor: Herbert S Diamond, MD  more...
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The OARSI recommmends intra-articular corticosteroid injections and oral nonselective NSAIDS for treatment of all subphenotypes. COX-2 selective oral NSAIDs were deemed apporpriate for individulals without comorbidities and mutiple-joint OA with moderate co-morbidity risk. Proton-pump inhibitor (PPI) co-prescription with oral NSAIDs is not recommended for those with no co-morbidity risk. For those with moderate or high co-morbidity risk receiving oral non-selective NSAIDs, PPI co-prescription is recommended. No recommendation was made for individuals taking  COX-2 selective oral NSAIDs at moderate mobidy risk. Use of oral NSAIDs is stongly advised against for individuals with high co-morbidity risk. [70]  

Duloxetine is recommended for most subphenotypes, however, associated adverse events and availability of more targeted therapies predicated uncertain appropriateness for individuals with knee-only OA and co-morbidities. [70]

Additional recommendations include [70] :

  • Acetaminophen for patients without co-morbidities
  • Topical capsaicin for knee-only OA without co-morbidities; uncertain for multiple-joint OA and in patients with co-morbidities
  • Topical NSAIDs for knee-only OA

For knee osteoarthritis, the ACR conditionally recommends using one of the following: 

  • Acetaminophen
  • Oral NSAIDs
  • Topical NSAIDs
  • Tramadol
  • Intra-articular corticosteroid injections

The ACR conditionally recommends against using chondroitin sulfate, glucosamine, or topical capsaicin for knee osteoarthritis. The ACR has no recommendations regarding the use of intra-articular hyaluronates, duloxetine, and opioid analgesics.

American Academy of Orthopaedic Surgeons guidelines

A 2013 clinical practice guideline from the American Academy of Orthopaedic Surgeons (AAOS) recommends the following pharmacologic treatments for symptomatic osteoarthritis of the knee [138] :

  • Oral NSAIDs
  • Topical NSAIDs
  • Tramadol

The AAOS was unable to recommend for or against the use of the following for symptomatic knee osteoarthritis:

  • Acetaminophen
  • Opioids
  • Pain patches
  • Intra-articular corticosteroid injections
  • Growth factor injections and/or platelet rich plasma

The recommendation on acetaminophen is a downgrade from the previous AAOS guideline, and reflects the use of new criteria that resulted in the selection of only one study, which found no statistical significance or minimum clinically important improvement with acetaminophen compared with placebo.

The AAOS does not recommend treatment with any of the following:

  • Intra-articular hyaluronic acid
  • Glucosamine and/or chondroitin sulfate or hydrochloride


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