As a clinical pharmacist, it's essential to emphasize that exercise (such as walking and strengthening exercises) and weight loss, if needed, remain the main approaches for management. It's important to note that while oral NSAIDs like naproxen are often effective, they may not be suitable for everyone due to potential risks to the heart, stomach, and kidneys. Expect the need for trial and error in finding the right treatment approach, and be prepared to utilize a combination of different options.
Why is acetaminophen falling out of favor? Educate that it's not very effective, even when given scheduled at up to 1 g QID. But it's generally safe and may do the trick for mild pain.
When should you consider topicals? Recommend topical NSAIDs (diclofenac, etc) for mild knee or hand pain if cost isn't an issue. They seem to cause fewer GI side effects than oral NSAIDs. But it's too soon to say they're safer from a CV or renal standpoint.
Or suggest trying OTC capsaicin (Capsin, etc), but it may not work as well as topical NSAIDs. Warn about burning and stinging. Keep in mind, these topicals require multiple daily dosing. Point out there's no proof other topicals (cannabidiol, lidocaine, methyl salicylate, etc) work, but some patients may find they help.
What is the role of other oral medications? Think of duloxetine for more widespread pain if oral NSAIDs can't be used. It has more evidence than gabapentin, SSRIs, tricyclics, etc. Evaluate duloxetine side effects (nausea, etc) and risks (falls, etc), then consider a 3-month trial. Save tramadol last-line to avoid stronger opioids or surgery.
When should intra-articular injections be given? Suggest a steroid injection for short-term relief of pain limited to one joint. But lean away from hyaluronic acid injections (Hyalgan, etc) due to limited efficacy and cost. And avoid stem cells, there's no proof they're effective, and there are safety concerns.
Which supplements can help? Explain that glucosamine SULFATE or SAMe may be worth a shot, chondroitin or MSM has less evidence. None are likely to harm but it can take a couple months to see any effect.
REFERENCES
Kolasinski, S.L., Neogi, T., and others (2020). 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research, 72(2), pp.149–162. Available at: https://pubmed.ncbi.nlm.nih.gov/31908149
Ebell, M.H. (2018). Osteoarthritis: Rapid Evidence Review. American Family Physician, [online] 97(8), pp.523–526. Available at: https://www.aafp.org/afp/2018/0415/p523.html
Hunter, D.J. and Bierma-Zeinstra, S. (2019). Osteoarthritis. The Lancet, 393(10182), pp.1745–1759. Available at: https://pubmed.ncbi.nlm.nih.gov/31034380