Executive summary
- Diagnosis: Diagnose CLINICALLY if: Age ≥45 AND Activity-related joint pain AND No morning stiffness (or <30 mins). X-ray is NOT needed unless red flags or surgery planned.
- Core Therapy: Therapeutic Exercise (muscle strengthening) + Weight Loss (if BMI >25). This is not "advice", it is the treatment.
- Strong Opioids: DO NOT OFFER (Tramadol, Oxycodone, Morphine) for OA. Risks > Benefits.
Pharmacological Ladder
- Step 1: Topical NSAID (First Line for Knee/Hand)
- E.g., Ibuprofen Gel / Diclofenac Gel. (More effective than Paracetamol, safer than oral NSAIDs).
- Step 2: Oral NSAID + PPI
- E.g., Naproxen 250mg-500mg bd + Omeprazole 20mg.
- Check: Renal function, HF risk, and bleeding risk. Use lowest effective dose.
- Step 3: Intra-articular Steroid
- Consider for moderate/severe pain to provide a window for engagement with exercise/physio.
- Note on Paracetamol: NICE NG226 downgraded Paracetamol. It can be used, but efficacy is low. Do not rely on it alone.
Referral for Surgery (Arthroplasty)
- Refer when:
- Joint symptoms (pain, stiffness, function) have a substantial impact on quality of life.
- AND non-surgical management (exercise, weight, meds) has been trialled and is refractory.
- Note: Do not delay referral solely because of age, sex, or obesity (though BMI optimisation is preferable).
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.