Patient information

1.3.1Offer accurate verbal and written information to all people with osteoarthritis to enhance understanding of the condition and its management, and to counter misconceptions, such as that it inevitably progresses and cannot be treated. Ensure that information sharing is an ongoing, integral part of the management plan rather than a single event at time of presentation. [2008]

Patient self-management interventions

1.3.2Agree individualised self-management strategies with the person with osteoarthritis. Ensure that positive behavioural changes, such as exercise, weight loss, use of suitable footwear and pacing, are appropriately targeted. [2008]

1.3.3Ensure that self-management programmes for people with osteoarthritis, either individually or in groups, emphasise the recommended core treatments (see recommendation 1.2.5), especially exercise. [2008]

Thermotherapy

1.3.4The use of local heat or cold should be considered as an adjunct to core treatments. [2008]

Exercise and manual therapy

1.4.1Advise people with osteoarthritis to exercise as a core treatment (see recommendation 1.2.5), irrespective of age, comorbidity, pain severity or disability. Exercise should include:

1.4.2Manipulation and stretching should be considered as an adjunct to core treatments, particularly for osteoarthritis of the hip. [2008]

Weight loss

1.4.3Offer interventions to achieve weight loss^[1] as a core treatment (see recommendation 1.2.5) for people who are obese or overweight. [2008]

Electrotherapy

1.4.4Healthcare professionals should consider the use of transcutaneous electrical nerve stimulation (TENS)^[2] as an adjunct to core treatments for pain relief. [2008]

Nutraceuticals

1.4.5Do not offer glucosamine or chondroitin products for the management of osteoarthritis. [2014]

Acupuncture

1.4.6Do not offer acupuncture for the management of osteoarthritis. [2014]

Aids and devices

1.4.7Offer advice on appropriate footwear (including shock-absorbing properties) as part of core treatments (see recommendation 1.2.5) for people with lower limb osteoarthritis. [2008]

1.4.8People with osteoarthritis who have biomechanical joint pain or instability should be considered for assessment for bracing/joint supports/insoles as an adjunct to their core treatments. [2008]

1.4.9Assistive devices (for example, walking sticks and tap turners) should be considered as adjuncts to core treatments for people with osteoarthritis who have specific problems with activities of daily living. If needed, seek expert advice in this context (for example, from occupational therapists or Disability Equipment Assessment Centres). [2008]

Invasive treatments for knee osteoarthritis

1.4.10Do not refer for arthroscopic lavage and debridement^[3] as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (as opposed to morning joint stiffness, 'giving way' or X-ray evidence of loose bodies). [2008, amended 2014]

Oral analgesics

1.5.1Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatments (see recommendation 1.2.5); regular dosing may be required. Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclo-oxygenase 2 (COX-2) inhibitors or opioids. [2008]

1.5.2If paracetamol or topical NSAIDs are insufficient for pain relief for people with osteoarthritis, then the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in older people. [2008]

Topical treatments

1.5.3Consider topical NSAIDs for pain relief in addition to core treatments (see recommendation 1.2.5) for people with knee or hand osteoarthritis. Consider topical NSAIDs and/or paracetamol ahead of oral NSAIDs, COX-2 inhibitors or opioids. [2008]

1.5.4Topical capsaicin should be considered as an adjunct to core treatments for knee or hand osteoarthritis. [2008]

1.5.5Do not offer rubefacients for treating osteoarthritis. [2008]

NSAIDs and highly selective COX-2 inhibitors

Although NSAIDs and COX-2 inhibitors may be regarded as a single drug class of 'NSAIDs', these recommendations use the two terms for clarity and because of the differences in side-effect profile.

1.5.6Where paracetamol or topical NSAIDs are ineffective for pain relief for people with osteoarthritis, then substitution with an oral NSAID/COX-2 inhibitor should be considered. [2008]

1.5.7Where paracetamol or topical NSAIDs provide insufficient pain relief for people with osteoarthritis, then the addition of an oral NSAID/COX-2 inhibitor to paracetamol should be considered. [2008]

1.5.8Use oral NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest possible period of time. [2008]

1.5.9When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg). In either case, co-prescribe with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost. [2008]

1.5.10All oral NSAIDs/COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal, liver and cardio-renal toxicity; therefore, when choosing the agent and dose, take into account individual patient risk factors, including age. When prescribing these drugs, consideration should be given to appropriate assessment and/or ongoing monitoring of these risk factors. [2008]

1.5.11If a person with osteoarthritis needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2 inhibitor (with a PPI) if pain relief is ineffective or insufficient. [2008]

Intra-articular injections

1.5.12Intra-articular corticosteroid injections should be considered as an adjunct to core treatments for the relief of moderate to severe pain in people with osteoarthritis. [2008]

1.5.13Do not offer intra-articular hyaluronan injections for the management of osteoarthritis. [2014]