Osteoarthritis: Management

Key points

• NICE now covers OA in NG226 (2022) , which replaced CG177 (2014). The emphasis shifted to therapeutic exercise as the core treatment, with reduced reliance on paracetamol and opioids.
• Offer therapeutic exercise (tailored muscle-strengthening and aerobic fitness) to everyone as a core treatment; support weight loss if overweight. Consider manual therapy (manipulation/mobilisation) alongside exercise for hip or knee OA.
• Topical NSAIDs are first-line pharmacological treatment, particularly for knee OA. Consider an oral NSAID (lowest effective dose, shortest time) only if a topical NSAID is ineffective or unsuitable, and co-prescribe a PPI for gastroprotection.
• Do NOT routinely offer paracetamol or weak opioids — only for infrequent, short-term relief when other pharmacological options are contraindicated, not tolerated or ineffective; explain there is no strong evidence of benefit for paracetamol. Do not offer strong opioids.
• Consider intra-articular corticosteroid injections only when other pharmacological treatments are ineffective/unsuitable or to support exercise — short-term relief only. Do not offer intra-articular hyaluronan injections, glucosamine, acupuncture, electrotherapy or arthroscopic lavage/washout.
• Diagnose OA clinically without imaging in people ≥45 with activity-related joint pain and either no morning stiffness or stiffness lasting ≤30 minutes.