Osteoarthritis

Description

General Measures

Medicine Treatment

Referral

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ICD-10 Code: M13.00-19/M16.0-9/M17.0-9/M18.0-9/M19.00-09/M19.80-99

DESCRIPTION

A disorder typically affecting weight-bearing joints and the hand (distal and proximal interphalangeals, and first metacarpophalangeal joints).

Signs and symptoms include:

• Pain on effort, relieved by rest.
• Morning stiffness, lasting < 30 minutes.
• Limited movement.
• Joint swelling (effusions and/or osteophytes).

GENERAL MEASURES

• Weight reduction.
• Exercise: postural and non-weight bearing. Quadriceps strengthening for knee involvement.
• Support and alleviate weight bearing of affected joints, i.e. walking stick.
• Physiotherapy and/or occupational therapy.

MEDICINE TREATMENT

When only pain relief is required:

• Paracetamol, oral, 1 g 4–6 hourly when required.
  • Maximum dose: 15 mg/kg/dose.
  • Maximum daily dose: 4 g in 24 hours.

If ineffective:

ADD

• NSAIDs e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with meals.

LoE:I¹²

• As many of these patients, particularly the elderly, have concomitant medical conditions such as cardiovascular, gastrointestinal disease or renal function impairment, NSAIDs must be used with caution.
• Patients on aspirin for cardiovascular risk reduction should take this agent 30 minutes before the 1st dose of NSAID in the morning, as taking aspirin and NSAID at the same time may reduce aspirin’s efficacy.

LoE:III¹³

In high-risk patients: > 65 years of age; history of peptic ulcer disease; or on concomitant warfarin, aspirin or corticosteroids:

LoE:II¹⁴

ADD

• PPI, e.g.:
  • Lansoprazole, oral, 30 mg daily.

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CAUTION

Use of all NSAIDs is associated with increased risks of gastrointestinal bleeding, renal dysfunction, and cardiovascular events (stroke and myocardial infarction).
NSAIDs should be used judiciously at the lowest effective dose for the shortest duration. Explore and manage exacerbating factors for pain. See Chronic pain.
Do not use NSAIDs in pregnancy or while breastfeeding.

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If ineffective:

Adjunct for pain control:

• Amitriptyline, oral, 10–25 mg at night.
  • Titrate dose according to response.
  • Initial dose in the elderly: 10 mg at night.
  • Maximum dose: 75 mg at night.

Intra-articular corticosteroids

Consider in cases where a joint is actively inflamed.
To be prescribed and administered by a specialist only.
Not more than 2–3 injections per year per joint are recommended.

• Intra-articular corticosteroid, e.g.:
  • Methylprednisolone acetate, 20–80 mg depending on joint size. 

LoE:III¹⁵

REFERRAL

• For consideration for joint replacement.
• Intractable pain.
• Neurogenic compression.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2024 Edition