The phone call from the Costco supplement aisle
Last Wednesday my neighbor Marcy called me from inside Costco. She was standing in the supplement aisle holding a tub of glucosamine sulfate the size of a coffee can, $34.99, two-month supply, and her husband Hal's knees had been waking him up at 4 a.m. for a month. "Vic," she said, "is this stuff actually anything?"
I told her to put the tub back, get the diclofenac gel from the pharmacy aisle two rows over, and call me when she got home.
That is the whole problem with the over-the-counter arthritis shelf in 2026. About thirty products promise joint comfort, the packaging is all roughly the same shade of teal, and almost no one (including some of the people stocking the shelf) can tell you which one the actual evidence supports for a 70-year-old knee. I have spent more time on this question than I would like to admit, because Frank's left knee has its own opinions since the replacement in 2021, and my own hands started filing complaints about three years ago. So I read the guidelines. I asked my internist. I'm going to walk you through the shelf the way I wish someone had walked me through it.
Quick disclaimer: I'm a 72-year-old former English teacher with a research habit, not a doctor. The point here is to send you to your doctor with better questions, not to replace the appointment.
Why the OTC math is different at 65 than at 45
The drugs that work fine for a 45-year-old runner work differently in a 70-year-old kidney. The 2023 American Geriatrics Society Beers Criteria, the standard reference list of medications that get riskier with age, flags chronic oral NSAID use in adults 65 and up. The risks rise sharply at 75. Acetaminophen has a lower daily ceiling for older adults than the bottle label suggests.
None of this is on the front of any package. So I am putting it on the front of this article.
Topical diclofenac gel: the actual first-line pick
If I could tell you only one thing on this list, this would be it. The 2019 American College of Rheumatology/Arthritis Foundation guidelines issue a strong recommendation for topical NSAIDs in knee osteoarthritis and hand osteoarthritis, and specifically prefer them over oral NSAIDs in adults over 75. Voltaren Arthritis Pain (diclofenac sodium 1% gel) went OTC in the United States in 2020. A 150-gram tube runs $20 to $25 at CVS or Walgreens. Apply 2 to 4 grams to the affected joint four times a day; the package has a dosing card.
The reason this matters: a topical NSAID delivers anti-inflammatory medication right to the joint without putting it through your stomach, your kidneys, or your cardiovascular system in any meaningful amount. The systemic absorption is a small fraction of an equivalent oral dose. For knees and hands, this is genuinely the right starting point for most older adults. The guideline calls hip OA "no recommendation," mostly because the hip joint is too deep for the gel to reliably penetrate.
This is the one my internist mentioned at my appointment last fall, said matter-of-factly, the way she'd mention sunscreen. I had somehow not heard it from anyone before that. Now you have.
Acetaminophen: still useful, no longer the default
For years the standard advice was "start with Tylenol." The evidence has shifted. A 2021 Cochrane review of fifteen randomized trials (nearly 6,000 participants) found acetaminophen statistically better than placebo for osteoarthritis pain, but the size of the benefit was clinically modest, and NSAIDs reliably outperformed it.
What acetaminophen is good for: filling the gaps. A short flare. A bad arthritis day where you need something on top of your topical. A patient who cannot tolerate any NSAID at all.
The dose ceiling matters more than the front of the bottle suggests. For older adults, most pharmacy guidance caps daily acetaminophen at 3 grams (six regular Extra Strength tablets), not the 4 grams the label allows. Lower than that if you have liver disease or regularly drink alcohol. The number to know is all sources: many cold medicines, sleep aids, and prescription combinations contain acetaminophen, and the total is what counts. This is the conversation to have with your pharmacist with all your bottles on the counter.
Oral ibuprofen and naproxen: the Beers Criteria conversation
Advil, Motrin, Aleve. The aisle has them in jars of 500. I know. They work. They are also the OTC choice with the most age-related risk.
The 2023 AGS Beers Criteria recommends avoiding chronic oral NSAID use in adults 65 and older unless other alternatives are ineffective and the patient is also taking a stomach-protecting medication (a proton pump inhibitor like omeprazole). The risks the guideline cites are not theoretical. Older adults on chronic NSAIDs have meaningfully higher rates of gastrointestinal bleeding, reduced kidney function, and cardiovascular events including heart attack. The risk curves steepen after 75.
This does not mean you cannot ever take an Advil. A short course (three days for a flare, taken with food) is a different conversation than a daily habit for six months. If you have any history of stomach ulcers, blood thinners (warfarin, apixaban, even daily low-dose aspirin), kidney disease, heart failure, or uncontrolled blood pressure, oral NSAIDs should not be a self-managed decision. Ask your doctor first.
Capsaicin cream: it works, but only if you stick with it
Capsaicin is the compound that makes chili peppers hot. Rubbed on a joint, it desensitizes the pain receptors over time. A 2024 meta-analysis in Phytotherapy Research found capsaicin four times daily moderately effective for OA pain out to 20 weeks. Two things from that paper worth knowing: the 0.075% concentration works faster (noticeable relief in days) than the more common 0.025% (about two weeks), and the burning sensation at the application site, which 35 to 100% of users report, is a feature, not a side effect. It fades after the first week or two.
The trap most people fall into: they try it for three days, the burning bothers them, they stop. Wash your hands carefully afterward, do not touch your eyes, and stick with it. If you cannot tolerate two weeks of warm-stinging, this is not your treatment.
Lidocaine 4% patches: what they do and do not do
The OTC lidocaine patches (Aspercreme, Salonpas, the generic versions) are a local anesthetic. They numb the surface. They are good for shallow pain: the bony part of a knee, the back of a hand, a tender spot on a thumb joint. They are useful overnight when a single joint is keeping you awake.
What they are not: anti-inflammatory. They do not address the underlying joint inflammation. They do not reach the deep cartilage. The prescription 5% lidocaine patch (Lidoderm) is FDA-approved for shingles nerve pain; the OTC 4% version is approved for temporary local pain relief. For a chronically inflamed joint, a patch is a layer in a strategy, not a strategy by itself. Many people combine it with a topical NSAID or oral acetaminophen, which is reasonable. Run the combination by your pharmacist.
The supplement aisle, sorted honestly
This is where Marcy's phone call lives. Three supplements deserve different verdicts.
Glucosamine and chondroitin. The big one, the popular one, the $34.99 Costco tub. The GAIT trial published in the New England Journal of Medicine in 2006 (1,583 patients, knee OA, 24 weeks) found neither glucosamine, nor chondroitin, nor the combination outperformed placebo for the overall study population. A subgroup with moderate-to-severe pain showed a small combination signal that has not replicated cleanly since. The 2019 ACR guidelines issue a strong recommendation against glucosamine or chondroitin for knee OA. For hand OA, they offer a conditional recommendation for it. So: if your hands ache, the trial of a few months is reasonable. If your knees ache, the money is better spent elsewhere. This is what I told Marcy, and why.
Turmeric/curcumin. A 2016 systematic review found curcumin extracts (the active compound in turmeric) noninferior to ibuprofen in a handful of small knee OA trials. Promising signal, small studies, evidence still building. The big caveat almost no one mentions: standard curcumin is poorly absorbed orally (bioavailability is famously bad), which is why the products that work, when they work, are formulated with piperine (black pepper extract) or a phospholipid complex. The label should say one of those things. Drug interaction flag: curcumin has mild blood-thinning effects. If you take warfarin or other anticoagulants, do not start a curcumin supplement without your pharmacist's blessing.
Omega-3 fish oil. Useful distinction: the evidence is stronger for rheumatoid arthritis (an autoimmune disease) than for osteoarthritis, the degenerative wear-and-tear kind most people over 60 have. A 2025 meta-analysis published in Frontiers in Medicine found omega-3 significantly helpful for chronic pain in RA but not meaningfully in OA. If you have RA, fish oil at the doses used in research (around 2 to 3 grams of EPA+DHA daily) is reasonable to discuss. If you have OA, you are buying it for the general cardiovascular benefit, not the joint.
Quick verdicts on the rest: SAM-e has modest small-study evidence comparable to NSAIDs in some trials; quality is inconsistent. Boswellia has moderate evidence over 4 or more weeks, often combined with MSM in products. MSM by itself has weak, inconsistent evidence.
The treatments that beat most of the bottles: weight and movement
Here is the thing nobody on the supplement aisle wants to put on a label. The two interventions with the strongest evidence for knee OA are not on the shelf at all.
A 10% reduction in body weight produces clinically meaningful improvement in knee OA pain and function. That is the headline from the NIH-backed IDEA trial and a stack of follow-up research. Dose-response: more weight off, more pain relief, demonstrably. For most older adults that is 15 to 20 pounds. Not 50. Not overnight. Just the same pound a week most doctors have been talking about forever, with arthritis pain as the specific payoff this time.
Exercise is conditionally or strongly recommended for OA across every joint site in the ACR guidelines: knees, hips, hands. Aerobic (walking, swimming, stationary bike), strength training (especially the quadriceps for knee OA), and balance work all count. The counterintuitive part most people miss: rest makes joint pain worse over weeks. Movement makes it better. Even when it feels like the opposite is true. Our pieces on gardening with arthritis and falls-prevention exercises are good places to start if you need an entry point.
Heat for stiffness, ice for acute flares. A heating pad in the morning, an ice pack after the activity that aggravated it. Boring, free, effective.
TENS units: try if other options are limited
Transcutaneous electrical nerve stimulation: a small battery-powered unit with electrode pads that deliver mild electrical pulses. Cochrane reviewed the evidence in 2019 and concluded the picture is mixed and the certainty low across chronic pain conditions overall. A 2022 systematic review specifically for knee OA found TENS reduced pain compared to control but did not improve function. Translation: it might take the edge off; it will not change the joint.
If you've tried the higher-evidence options and want one more drawer in the toolkit, an OTC TENS unit runs $30 to $80 and is reasonably safe. Skip it if you have a pacemaker.
When the OTC aisle isn't enough: the doctor script
If you've worked through topical NSAIDs, an exercise plan, weight strategy if it applies, and a sensible combination of the above for three months and you still have pain that interrupts your sleep or limits walking, that's the appointment.
A short script that gets you out of the appointment with options instead of more advice:
- "I've tried diclofenac gel four times a day for [X weeks], and acetaminophen as needed. My pain is still [number] out of 10 and it's keeping me from [specific activity]. What's next?"
- Ask about duloxetine (Cymbalta), an SNRI antidepressant the FDA also approves for chronic musculoskeletal pain. The 2019 ACR guidelines conditionally recommend it for OA pain. It is particularly useful when stomach or kidney issues rule out oral NSAIDs.
- Ask about intra-articular injections: corticosteroid injections for short-term relief, hyaluronic acid injections for some patients, depending on the joint and the picture.
- Ask for a physical therapy referral. Medicare Part B covers it. A six-visit PT script for a specific joint is one of the most underused tools in this entire conversation.
- Ask whether an orthopedist consult is warranted. For advanced knee or hip OA, the surgical conversation is not a defeat. Frank's knee replacement was the best decision he made in his 70s, and I am the one who said two years earlier that he was overreacting. I was wrong. He sleeps now.
The OTC shelf can carry you a long way. Walking into the appointment with the right questions is the rest of the job.
Marcy put the glucosamine back. She picked up the Voltaren. Three weeks in, Hal sleeps through the night again. The tub on the shelf at Costco is still there. I checked.
