Guideline 819FM.3 1 of 2 Uncontrolled if printed
819FM.3 PHARMACOLOGICAL MANAGEMENT OF KNEE AND HAND
OSTEOARTHRITIS IN ADULTS
Target Audience: Primary and Secondary Care
Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of
functional limitation and reduced quality of life. It is the most common form of arthritis, and
one of the leading causes of pain and disability worldwide. Osteoarthritis is characterised
pathologically by localised loss of cartilage, remodelling of adjacent bone and associated
inflammation. In addition to holistic and non-pharmacological management, pharmacological
management should be offered.
All drugs need a trial of 2 - 4 weeks unless there is intolerance. Aim to use the lowest
effective dose for the shortest time possible. Do not prescribe rubefacients.
Step 1: Paracetamol 1 g orally four times a day regularly
Step 2: Add topical non-steroidal anti-inflammatory drugs (NSAIDS)
• Ibuprofen gel 5% or 10%, applied up to three times a day
• Diclofenac 1.16% gel applied up to four times a day
• Piroxicam 0.5% gel applied up to four times a day
NB. Other than ibuprofen 10% gel, these are available over the counter. Topical
application in large amounts can result in systemic side effects and the possibility of drug
interactions.
Step 3: Consider adding oral NSAID or selective COX-2 inhibitor, and stop topical
NSAID.
The choice of drug will depend on individual patient risk factors (Refer to BNF, NICE CKS
NSAIDs-prescribing issues or Buckinghamshire Healthcare NHS Trust (BHT) Guideline
299FM Prescribing Non-steroidal Anti-inflammatory Drugs (NSAIDs) in Adults). Absolute
contraindications include allergic reaction, gastrointestinal (GI) bleeding/ulceration, severe
heart failure, severe hepatic impairment or severe renal impairment with estimated
glomerular filtration rate (eGFR) <30 mL/minute/1.73 m2).
Drugs to consider
• Ibuprofen 400 mg three times a day - usually used first line due to more favourable
adverse event profile. (NB. Higher doses up to 2.4 g per day can be used if no
cardiovascular risk factors.)
• Naproxen 250 – 500 mg twice a day (AVOID if gastrointestinal bleed risk factors).
• Diclofenac 25 – 50 mg three times a day (AVOID if cardiovascular disease risk
factors).
• COX-2 inhibitors (celecoxib 200 mg daily increased up to 200 mg twice daily or
etoricoxib 30 mg once a day). Lower risk of serious GI bleeding than with the
above non-selective NSAIDs, but avoid if cardiovascular disease risk factors.
NSAIDs/COX-2 inhibitors should be co-prescribed with a proton pump inhibitor (PPI) (e.g.
lansoprazole 15 – 30 mg OD or omeprazole 20 - 40 mg OD). Ensure higher dose if on
oral anticoagulants or any increased risk of a GI bleed. If on low-dose aspirin, consider
other analgesics (see step 4) before using an NSAID or COX-2 inhibitor due to increased
GI bleeding risk.
Frequent review and monitoring for adverse effects is required.
