Is Hyaluronic Acid Injection the First-Line Treatment for Osteoarthritis?

Understanding First-Line Therapy for Osteoarthritis

When it comes to managing osteoarthritis (OA), a degenerative joint condition affecting millions worldwide, evidence-based guidelines consistently recommend oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the initial, first-line pharmacological treatment—not intra-articular hyaluronic acid (HA) injections. Medications such as diclofenac sodium, loxoprofen sodium, and etoricoxib have demonstrated robust clinical efficacy in reducing pain, decreasing stiffness, and improving functional mobility in patients with mild-to-moderate OA—particularly in weight-bearing joints like the knee and hip.

Why NSAIDs Come First—And When to Consider Alternatives

These oral NSAIDs work by inhibiting cyclooxygenase (COX) enzymes, thereby lowering prostaglandin production and systemic inflammation. Clinical trials and real-world data show rapid symptom relief within days to weeks, making them highly practical for early-stage intervention. However, their use requires careful risk-benefit assessment: long-term or high-dose NSAID therapy may increase the risk of gastrointestinal irritation, ulcers, hypertension, or renal impairment—especially in older adults or those with comorbidities.

When Hyaluronic Acid Injections Enter the Picture

Hyaluronic acid injections are not considered first-line but rather a second-line, adjunctive option—typically reserved for patients who either fail to respond adequately to oral NSAIDs, experience intolerable side effects, or have contraindications (e.g., active peptic ulcer disease, chronic kidney disease, or concurrent anticoagulant use). Administered directly into the affected joint space, HA acts as a viscosupplement: it restores lubrication, dampens inflammatory mediators, and may support chondrocyte metabolism—offering potential symptomatic relief for 6–12 months in select individuals.

Evidence, Expectations, and Patient-Centered Decision Making

While meta-analyses suggest modest but statistically significant improvements in pain and function with HA injections—especially in knee OA—the effect size is generally smaller than that seen with optimized NSAID regimens. Importantly, treatment success depends heavily on proper patient selection, accurate injection technique (ideally ultrasound-guided), and integration with core non-pharmacologic strategies: weight management, structured physical therapy, low-impact exercise (e.g., swimming or cycling), and biomechanical support (e.g., orthotics or bracing). Always consult a board-certified rheumatologist or sports medicine specialist to tailor a safe, sustainable, and guideline-aligned OA management plan.