For osteoarthritis, the pharmacological approach is around oral analgesics, topical treatments, and anti-inflammatory drugs. NICE's clinical guideline on osteoarthritis, CG 177, starts with paracetamol alongside 'core interventions' of providing information about managing pain, encouraging more activity and exercise, and weight loss if a factor.19

€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,€ it says. €If 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.€

Topical NSAIDs may also be considered alongside paracetamol and core treatments for people with knee or hand osteoarthritis, with priority given over oral NSAIDs, COX-2 inhibitors or opioids. Topical capsaicin can be added, but rubefacients should be avoided.

If paracetamol or topical NSAIDs are ineffective, then substitution with an oral NSAID/COX-2 inhibitor can be considered. If there is insufficient pain control with paracetamol or topical NSAIDs, then oral NSAIDs/COX-2 inhibitors can be added.

However, the guidance continues: €Use oral NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest possible period of time. When 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 60mg). In either case, co-prescribe with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost.€

NICE notes that analgesic effects of NSAIDs/COX-2 inhibitors are of similar magnitude, but vary in their side effect profiles, so patient risk factors and monitoring need consideration.

In more severe cases, intra-articular corticosteroid injections may have a role in moderate to severe pain, but intra-articular hyaluronan injections are not recommended.