TreatmentTreatments for Knee Arthritis Sorted by Relative Effectiveness

Treatments for Knee Arthritis Sorted by Relative Effectiveness

Up to forty percent of Americans over 45 have pain from wear and tear on their knee joints. Numerous over-the-counter (OTC) and prescription (Rx) medications are available to treat osteoarthritis, but how effective are they in comparison to one another? This crucial subject might get some clarity according to a recent meta-analysis that was published in the Annals of Internal Medicine. Following three months of administration, the following therapies were compared for their ability to alleviate pain, strongest to weakest:

  1. Hyaluronic acid injection via gel (Rx)

#2. Steroid knee injection (Rx corticosteroid)

  1. Diclofenac (Oral NSAID prescribed by Voltaren)

The OTC oral NSAID #4 is Ibuprofen (Motrin).

#5. Naproxen (Alleve; over-the-counter oral NSAID)

  1. Celecoxib (Rx NSAID, Celebrex)

#7. Placebo injection using saline solution in the knee

#8. Acetaminophen (P-aminophenol-derived synthetic nonopiate over-the-counter medicine, Tylenol)

#9. A sugar pill, or oral placebo

This rank order list piqued my curiosity for several reasons. First off, it seems that celecoxib and acetaminophen are not as helpful as I had thought. Second, the more intrusive the placebo, the more successful it may be (saline injections into the knee outperform acetaminophen and sugar pills by a wide margin). Third, the surprisingly effective injection of cushion gel fluid is attributed to a mode of action that is not centered around the direct reduction of inflammation, which is the mainstay of most arthritis therapies. Has the use of mechanical pain therapies been underutilized? Lastly, there is no clinically significant difference between acetaminophen first line therapy and placebo.

Naturally, there are a few disclaimers attached to this material. Treatments for arthritic pain must first be tailored to each patient’s specific tolerances and risk profiles. In addition, patients with severe arthritis may benefit from “crossing the line” and starting with stronger medications. Mild pain does not always require the use of medications that entail higher risks (such as gastrointestinal bleeding or joint infection). The study’s limitations include the fact that therapies were only tested for a three-month trial period, and since the comparative effectiveness was determined based on the patient groups, we cannot be positive that they were substantially similar.

Having said that, this study will affect how I practice. In my future work, I anticipate that I will tend to offer more efficacious therapy to my patients, avoiding the use of celecoxib and acetaminophen altogether and giving serious thought to injections and diclofenac for moderate to severe OA and ibuprofen/naproxen for mild to moderate OA. Furthermore, as we already know, there is no discernible difference between glucosamine and chondroitin and a placebo, so do not waste your money on those supplements. If we do not stop eating pricey placebos, the racket is predicted to grow into a $20 billion industry by 2020.

Ultimately, the most important point to note is that exercise and weight loss remain the most effective therapy for osteoarthritis in the knee. To learn more about the entire range of treatment choices, check out the American Academy of Orthopedic Surgery’s most recent list of evidence-based recommendations for the management of knee arthritis.

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