Version July 2025
INTRODUCTION —
Osteoarthritis (OA) is the most common form of arthritis and can often be disabling in adults. Although many pharmacologic and nonpharmacologic options are available for the symptomatic treatment of OA, the presence of comorbidities remains a practical challenge that complicates management and may require adjustment of treatment plans. Clinicians should also consider how optimizing OA management in this population can also improve outcomes related to comorbidities, improving the patient's overall health.
This topic will review the management of OA in patients with common comorbidities. The pathogenesis, risk factors, diagnosis, clinical manifestations, and treatment of OA are presented separately:
●(See "Pathogenesis of osteoarthritis".)
●(See "Epidemiology and risk factors for osteoarthritis".)
●(See "Clinical manifestations and diagnosis of osteoarthritis".)
●(See "Overview of the management of osteoarthritis".)
●(See "Management of knee osteoarthritis" and "Management of moderate to severe knee osteoarthritis".)
BACKGROUND —
The prevalence of comorbidities among patients with OA is high [1-6]. In a meta-analysis of 42 studies, the prevalence of any comorbidity in individuals with OA was 67 percent (95% CI 57-74) versus 56 percent in individuals without OA (95% CI 44-68) [1]. The leading chronic conditions among patients with OA included hypertension in 50 percent, cardiovascular disease (CVD) in 35 percent, peptic ulcer disease in 16 percent, and diabetes in 14 percent. Patients with OA are twice as likely to have CVD [5] and nearly 40 percent more likely to have diabetes [6]. In another meta-analysis, among patients with OA, the prevalence of depression and anxiety was 20 percent and 21 percent, respectively [2].
Shared risk factors, including older age and obesity, may contribute to the high co-prevalence of comorbidities. Studies have also shown that poor mobility resulting from symptomatic OA increases the risk of developing comorbidities such as CVD [7] and diabetes [8], while OA pain may more directly contribute to depression [9]. Conversely, greater comorbidity burden with cardiac disease, diabetes, or back pain has been shown to contribute to worse pain and physical function in patients with knee and/or hip OA [10]. Findings from a systematic review suggest that having at least one comorbidity is one of the factors associated with a worse evolution of pain over several years [11]. Finally, several studies have found a link between the presence of comorbidities and greater use of opioid analgesics in people with OA [12,13].
Several studies have also suggested that OA is associated with excess mortality risk [14-16] (see "Overview of the management of osteoarthritis", section on 'Mortality'). In a meta-analysis including 10,723 patients with knee OA, the presence of pain had a 37 percent increased association with reduced time to mortality in an adjusted model [16].
MANAGEMENT CONSIDERATIONS FOR COMORBIDITIES —
While the presence of comorbidities in patients with OA impacts treatment choices, most of the same general management principles of OA apply. All patients should engage in nonpharmacologic measures, such as weight management and exercise, braces, walking aids, and psychologic interventions as appropriate (see "Overview of the management of osteoarthritis", section on 'Overview of management'). The beneficial effects of exercise and weight loss are not only limited to OA but are also advantageous for several other comorbidities, underscoring their importance in these patients. Facilitating ways that patients with OA and comorbidities can adhere to comprehensive first-line measures should be a priority, recognizing that these individuals have competing demands related to managing multiple conditions and often benefit from added support.
We discuss specific considerations when managing OA in the setting of the common comorbidities listed below. Our approach to managing OA patients with comorbidities is generally consistent with those that have been addressed by major guidelines [17-19].
Diabetes mellitus — We use oral nonsteroidal anti-inflammatory drugs (NSAIDs) with caution when treating OA patients with diabetes mellitus (DM), particularly among those with complications such as cardiovascular disease (CVD) or who use angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs). We avoid NSAIDs in those with kidney disease. Adverse effects of NSAIDs among patients with kidney disease and CVD are discussed in detail elsewhere. (See "NSAIDs: Adverse cardiovascular effects" and "NSAIDs: Acute kidney injury".)
Other oral pharmacologic agents and supplements used in the treatment of OA appear to be safe, but few have been studied specifically in the context of DM. There are some data that support the safety of glucosamine among patients with DM. An analysis of safety data from one randomized trial found that the mean plasma glucose levels in the group of patients taking glucosamine did not differ from baseline at both the three- and six-month follow-up period [20]. Also, a subgroup analysis of hyperglycemic patients at baseline found that mean glucose levels tended to decrease over time with glucosamine compared with placebo. Additional information regarding the use of glucosamine and chondroitin for OA can be found elsewhere. (See "Management of knee osteoarthritis", section on 'Nutritional supplements'.)
Intra-articular glucocorticoid injections pose a theoretical risk to patients with DM by potentially raising blood glucose to hyperglycemic levels. However, patients generally experience an isolated increase in blood glucose for one to two days after the injection, which rarely poses a significant clinical risk when DM is well controlled. For patients with insulin-dependent diabetes in whom an intra-articular injection is warranted, self-monitoring of blood glucose should be performed for up to three to five days after the injection. In a case-crossover study of 40 patients with type 1 or 2 DM, the fasting blood glucose level was increased one and two days after a glucocorticoid injection for common conditions in the hand and wrist (eg, trigger finger, carpal tunnel syndrome, OA), especially in patients with insulin-dependent diabetes. Fasting blood glucose concentration did not differ after the second postinjection day [21]. In another study with 23 patients with DM, an extra-articular wrist injection of 10 mg of triamcinolone acetonide increased blood glucose levels during five days after injection as compared with morning blood glucose levels preinjection [22]. Patients who were insulin dependent experienced greater changes from baseline compared with those who were non-insulin dependent. Additional information regarding the use of intra-articular glucocorticoid injections in the management of knee OA is discussed separately. (See "Management of moderate to severe knee osteoarthritis", section on 'Limited role of intra-articular glucocorticoid injections'.)
Hypertension — We generally limit the use of oral NSAIDs in OA patients with hypertension to those whose hypertension is well controlled and who have preserved kidney function. All NSAIDs at therapeutic doses can increase blood pressure in both normotensive and hypertensive individuals. Cyclooxygenase 2 (COX-2) inhibitor NSAIDs seem to have more prohypertensive effects than nonselective NSAIDs [23]. In a meta-analysis that measured the hypertensive effects of various nonselective NSAIDs, indomethacin, naproxen, and piroxicam appeared to have a greater effect on increasing blood pressure relative to ibuprofen and sulindac [24].
Oral NSAID use may also reduce the effect of all antihypertensive drugs except calcium channel blockers [25]. NSAIDs should be used with caution in those taking ACE inhibitors and ARBs, particularly also in combination with a diuretic, due to the risk of acute kidney injury. The use of NSAIDs in patients with OA and other comorbidities is discussed below (see 'Cardiovascular disease' below and 'Chronic kidney disease' below and 'Peptic ulcer disease and NSAID use' below). A detailed discussion of the effect of NSAIDs on blood pressure is presented separately. (See "NSAIDs and acetaminophen: Effects on blood pressure and hypertension".)
Although acetaminophen is no longer a preferred agent in the management of OA, it is not contraindicated in OA patients with hypertension. While there have also been some studies suggesting an increased effect on blood pressure with acetaminophen [26], the data are mixed, with most studies reporting no effect [20,27-29]. (See "NSAIDs and acetaminophen: Effects on blood pressure and hypertension".)
Intra-articular glucocorticoid injections do not appear to have a significant effect on blood pressure, based largely on data from patients with rheumatoid arthritis [30-32]. However, considering the known effects of systemic glucocorticoids on blood pressure, the blood pressure may be evaluated for three to five days after the injection in patients with poorly controlled hypertension or the injection deferred until blood pressure has been controlled.
Cardiovascular disease — The cardiovascular safety of NSAIDs is highly controversial, particularly in individuals with serious CVD [33]. In patients with serious or unstable CVD, we avoid the use of both selective and nonselective NSAIDs. For those with stable CVD in whom an NSAID is necessary, we preferentially use naproxen. A meta-analysis of 280 trials of NSAIDs versus placebo found that naproxen did not significantly increase major vascular events [34]. A detailed discussion on the adverse cardiovascular effects of NSAIDs is presented separately. (See "NSAIDs: Adverse cardiovascular effects".)
Regular NSAID use should also be avoided in patients taking low-dose aspirin for cardiovascular protection due to the increased risk of bleeding, particularly from the gastrointestinal tract. In patients on aspirin who require NSAIDs on an occasional, short-term basis, aspirin should be taken at least two hours before the NSAID. We avoid use of NSAIDs in those taking other antiplatelet agents or anticoagulants due to the risk of gastrointestinal bleeding. (See "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity".)
Patients with OA and walking disability are at increased risk of death from cardiovascular causes [14]. Thus, management of OA in patients with CVD should focus on approaches that will improve walking disability and promote physical activity [14]. Nonpharmacologic therapies, including exercises; braces; education; and the use of assistive devices, such as canes, should be emphasized. Moreover, cardiovascular rehabilitation programs that increase physical activity have a positive impact on both CVD and OA. The benefits and risks of exercise in patients with CVD, as well as an approach to prescribing exercise, are discussed in detail separately. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary artery disease".)
Among pharmacologic treatments that are commonly used to treat OA, we prioritize local treatments, including topical agents (eg, topical NSAIDs, capsaicin) and intra-articular glucocorticoid injections, rather than systemic therapies for patients with CVD. However, when appropriate, other systemic therapies used in the treatment of OA, such as duloxetine, can be used in patients with CVD. (See "Management of knee osteoarthritis", section on 'Topical NSAIDs' and "Management of moderate to severe knee osteoarthritis", section on 'Duloxetine'.)
There are limited data regarding cardiovascular effects with analgesics other than NSAIDs, most of which are limited to acetaminophen. As mentioned above, acetaminophen is no longer a preferred agent for the treatment of OA [35]. There are conflicting data on the effect of acetaminophen on CVD [35-38]. A large, population-based study including 10,878 patients over the age of 65 who were exposed to acetaminophen during a 10-year period found that there was no associated increased risk of myocardial infarction or stroke [37,38]. However, a systemic review that included four observational studies with data on adverse cardiovascular events found a dose-response increase with acetaminophen in the risk ratio of cardiovascular adverse events in each of the studies [35]. (See "Management of knee osteoarthritis", section on 'Oral therapies'.)
Opioids have been associated with an increased risk of myocardial infarction and all-cause mortality when used long term [39,40]. Due to their adverse effect profile and paucity of evidence for long-term symptomatic benefit, we avoid the use of opioids [41,42] in people with OA. (See "Use of opioids in the management of chronic pain in adults", section on 'Monitoring for adverse effects'.)
Chronic kidney disease — We avoid the use of oral NSAIDs in the management of OA patients with chronic kidney disease, especially stages 3 and 4, given the risk of contributing to chronic kidney disease progression. NSAIDs should be used with caution in those taking ACE inhibitors and ARBs, due to the risk of acute and acute-on-chronic kidney injury. A detailed discussion of the NSAIDs and their effect on kidney function is presented separately. (See "NSAIDs: Acute kidney injury" and "Management of chronic pain in advanced chronic kidney disease", section on 'Drugs that should be avoided'.)
Among pharmacologic treatments that are commonly used to treat OA, we prefer local treatments, including topical agents (eg, topical NSAIDs, capsaicin) and intra-articular glucocorticoid injections, rather than systemic therapies in patients with chronic kidney disease. (See "Management of knee osteoarthritis", section on 'Topical NSAIDs' and "Management of moderate to severe knee osteoarthritis", section on 'Limited role of intra-articular glucocorticoid injections'.)
Peptic ulcer disease and NSAID use — The recurrence of ulcer complications with continued use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) is well established and is contraindicated when treating OA patients with active peptic ulcer disease (eg, active bleeding or perforation). (See "Overview of complications of peptic ulcer disease", section on 'Discontinue NSAIDs'.)
In patients with a history of peptic ulcer disease or at elevated risk for gastroduodenal disease, we prefer topical NSAIDs. For those who require oral NSAIDs, we combine an NSAID with a gastroprotective agent (eg, a proton pump inhibitor). COX-2 inhibitors may be safer than nonselective NSAIDs for reduction in the risk of gastrointestinal bleeding but are still associated with an increased risk. The relative gastrointestinal toxicity of different NSAIDs and prevention of NSAID-induced gastroduodenal damage are discussed in detail separately. (See "NSAIDs (including aspirin): Treatment and secondary prevention of gastroduodenal toxicity".)
Obesity and weight loss — The importance of maintaining a healthy weight should be emphasized for all patients with OA. The decision to pursue nonpharmacologic, pharmacologic, or surgical approaches to weight loss is guided by obesity class, prior treatments, and patient preferences. Obesity is associated with lower limb and hand OA and can worsen pain and functional disability [43,44]. Obesity also has a direct mechanical effect on weightbearing joints, as do various substances in adipose tissue, such as adipokines and inflammatory proteins (see "Pathogenesis of osteoarthritis", section on 'Risk factors'). The approach to the management of obesity is discussed separately. (See "Obesity in adults: Overview of management".)
Weight loss has been shown to reduce both pain and disability in patients with knee OA. As an example, in a randomized trial with 399 patients with knee OA and obesity, the association of diet-induced weight loss (≥10 percent) and physical exercise for 18 months was more effective on pain and mobility than each intervention alone [45]. In a meta-analysis of 19 randomized trials of patients with knee or hip OA, weight reduction was found to provide small to moderate improvement in pain and disability [46]. There is also some evidence to suggest that weight loss may have a structural effect on OA. In a study with 112 patients with obesity, weight loss was associated with reduced medial-tibial cartilage volume loss (but not lateral and patella cartilage) and improved knee symptoms (pain, stiffness, and function) [47]. To avoid excessive loss of lean mass that has the potential to compromise joint health and symptoms [48], we recommend concomitant exercise as part of a weight loss program.
Depression — Prior studies have shown a bidirectional relationship between OA pain and depressive symptoms [9]; while OA pain contributes to the risk of depression, depressive symptoms amplify OA pain. We recommend that patients with OA and depression receive appropriate mental health support to support their OA management and overall well-being.
Exercise programs should be emphasized for those with OA and depression, as both conditions may benefit. A meta-analysis including 41 studies found that exercise has large effects on depressive symptoms [49]. Another meta-analysis in people with OA found mind-body approaches may be particularly beneficial [50]. While duloxetine, a serotonin-norepinephrine reuptake inhibitor, is approved for OA pain, in those with depression, we recommend clinicians select an antidepressant medication best suited for the mood disorder, as ameliorating mood will importantly improve OA pain and function [51].
SPECIAL CONSIDERATIONS IN OLDER ADULTS —
In older adults with OA, optimizing drug therapy is more challenging. Drug metabolism may differ in older patients, and the risk of toxicity is increased. Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids may all have increased adverse effects in this population. (See "Drug prescribing for older adults".)
The metabolism of acetaminophen in older patients is highly variable and may be reduced in frail older patients due to a decreased volume of distribution and intrinsic conjugative activity of the liver [52]. Thus, older adults may be at increased risk of hepatotoxicity, and the maximum daily dose should likely be reduced to between 2 and 3 g/day (see "Cancer pain management: Use of acetaminophen and nonsteroidal anti-inflammatory drugs", section on 'Hepatic toxicity'). NSAIDs have also been shown to increase the risk of gastrointestinal, cardiovascular, and kidney adverse effects in older adults [52] (see "Nonselective NSAIDs: Overview of adverse effects" and "Overview of COX-2 selective NSAIDs", section on 'Toxicities and possible toxicities'). Opioid use in older adults is associated with an increased risk of cognitive impairment, delirium, or injuries (eg, falls, fractures) and may also increase the risk of cardiovascular events, pneumonia, hospitalization, and mortality [52,53]. (See "Treatment of chronic non-cancer pain in older adults", section on 'Opioids'.)
In older adults, the same exercise recommendations apply. For those with cognitive impairment, a supervised program, whether by a health professional or caregiver, is recommended to provide sufficient direction, motivation, and support. (See "Physical activity and exercise in older adults".)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Osteoarthritis".)
SUMMARY AND RECOMMENDATIONS
●Background – The presence of comorbidities in patients with osteoarthritis (OA) often impacts treatment choices, particularly with respect to pharmacologic therapy. (See 'Background' above and 'Management considerations for comorbidities' above.)
●Management considerations for comorbidities
•Diabetes mellitus – We use oral nonsteroidal anti-inflammatory drugs (NSAIDs) with caution when treating OA patients with diabetes mellitus (DM), particularly among those with complications such as cardiovascular disease (CVD) or who use angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs). We avoid NSAIDs in those with kidney disease. (See 'Diabetes mellitus' above and "NSAIDs: Adverse cardiovascular effects" and "NSAIDs: Acute kidney injury".)
Intra-articular glucocorticoid injections pose a theoretical risk to patients with DM by potentially raising blood glucose to hyperglycemic levels. However, patients generally experience an isolated increase in blood glucose for one to two days after the injection, which rarely poses a significant clinical risk when DM is well controlled. For patients with insulin-dependent diabetes in whom an intra-articular injection is warranted, self-monitoring of blood glucose should be performed for up to three to five days after the injection. (See 'Diabetes mellitus' above.)
•Hypertension – We generally limit the use of oral NSAIDs in OA patients with hypertension to those whose hypertension is well controlled and who have preserved kidney function. NSAIDs should be used with caution in those taking ACE inhibitors and ARBs, particularly also in combination with a diuretic, due to risk of acute kidney injury. (See 'Hypertension' above.)
•Cardiovascular disease – In patients with serious CVD, the use of both selective and nonselective NSAIDs should be avoided. For patients in whom an NSAID is necessary, we prefer naproxen because of a lower risk of cardiovascular events. (See 'Cardiovascular disease' above and "NSAIDs: Adverse cardiovascular effects", section on 'NSAID characteristics'.)
•Chronic kidney disease – We avoid the use of NSAIDs in the management of OA patients with chronic kidney disease, especially stages 3 and 4, given the risk of contributing to chronic kidney disease progression. (See 'Chronic kidney disease' above.)
•Peptic ulcer disease – In patients with a history of peptic ulcer disease or at elevated risk for gastroduodenal disease who require NSAIDs, we combine an NSAID with a gastroprotective agent (eg, a proton pump inhibitor). (See "NSAIDs (including aspirin): Treatment and secondary prevention of gastroduodenal toxicity".)
•Obesity – The importance of healthy weight maintenance should be emphasized for all OA patients. Obesity is associated with lower limb and hand OA and can worsen pain and functional disability. (See 'Obesity and weight loss' above and "Management of knee osteoarthritis", section on 'Weight loss'.)
•Depression – In patients with depressive symptoms, including major depressive disorder, exercise should be emphasized. Optimizing nonpharmacologic and pharmacologic therapies for depression will improve OA pain and function.
•Older age – Optimizing drug therapy is more challenging in older adults with OA. Drug metabolism may differ in older patients, and the risk of toxicity is increased. NSAIDs, acetaminophen, and opioids may all have increased adverse effects in this population. Older adults should be supported to engage in recommended exercise. (See 'Special considerations in older adults' above.)
ACKNOWLEDGMENTS —
The UpToDate editorial staff acknowledges Francis Berenbaum, MD, PhD, and Karine Louati, MD, who contributed to earlier versions of this topic review.
