How do you treat pain in osteoarthritis?

Question

This is a commonly asked question on USMLE Step 2. The first line in addressing pain in osteoarthritis, in case the patient has not tried any interventions yet, is nonpharmacologic. This classically comprises exercises (e.g. exercises to strengthen the quadriceps), and weight loss. Since obesity is a risk factor for osteoarthritis due to increased stress placed on the knee and back joints, weight loss is a very significant recommendation for patients with the disease. Once nonpharmacologic measures have been attempted, NSAIDs and Tylenol can be used to control the pain and inflammation. The classic NSAID used on STEP 2 is topical ketorolac for osteoarthritis management. Alternatively ibuprofen can be used, and tylenol is another medication commonly used in OA.

Once we have attempted NSAIDs and/or tylenol, and if the patient continues to have pain, the next line is typically steroid injections. This is another phenomenal way of controlling both pain and inflammation at the joint site. If the patient is a good surgical candidate and if the patient has OA of the knee, for instance, surgical interventions can be considered. These interventions typically include a TKA (Total Knee Arthroplasty) for patients who are good surgical candidates. This is typically the last line of treatment, and the question stem will mention that the previous therapeutic interventions have already been attempted in patients for whom surgery is indicated.

Answer 1

Stupidly, the answer for the USMLE, or any medical exam, treatment in this order for OA

1. nonpharmacologic interventions as above: weight loss, orthotics
2. .Topical treatments: NSAIDS, Casaicin, Lidocaine
3. oral meds: 1st line- Tylenol, then NSAIDS, Tramadol, Duloxetine, Opiods (last resort)
4. Intraarticular injections: (no proven benefit by guideline, everyone knows they do!)
5. . Surgery

Not long ago, NSAIDS were the 1st line treatment of choice in any arthritis. (still should be). Note Tylenol will not help osteoarthritis.(maybe trivially for discomfort in a few). Note Osteoarthritis is an INFLAMMATORY DZ. SO NSAIDS work. STEROIDS work best, (Short term), Many rheumatologist use DMARDS that work when they can get paid for it. When money changes, therapy changes

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