26th January 2024

Pharmacological management

If non-pharmacological approaches do not achieve adequate symptom control, pharmacological management strategies are required, although these can often be used on an as-required basis in some patients. 

Patients are initially advised to use simple analgesia such as paracetamol and topical non-steroidal anti-inflammatory drugs (NSAIDs), especially in hand or knee involvement, provided there are no contraindications to treatment. Potential adverse effects of paracetamol include hepatic toxicity, although this is rare at low doses. Patients using topical ibuprofen should be advised against the risk of severe burns in the presence of naked flames. If these drugs fail to produce sufficient symptomatic control, oral NSAIDs such as ibuprofen or COX 2 inhibitors such as etoricoxib and celecoxib can be used in conjunction with a proton pump inhibitor. Care should be taken, especially when prescribing these drugs in the elderly or those with renal, cardiac or gastrointestinal problems. NSAIDs and COX-2 inhibitors should be used at the lowest effective dose for the shortest period of time possible. Selective COX-2 inhibitors are associated with reduced risk of gastrointestinal side effects compared with NSAIDs, but carry a similar risk of renal toxicity. A careful selection of drugs and adequate patient education are required to maximise the risk-to-benefit ratio. If oral NSAIDs are being used, treatment with topical NSAIDs should be stopped. If the above treatment is ineffective, opioids such as codeine can be used if there are no contraindications. Topical capsaicin can be considered, especially for hand or knee involvement. In patients with acute exacerbations of OA in the knee or hip with moderate to severe pain, intra-articular corticosteroid injections can be considered as adjuncts to treatment.