Non-pharmacological

Patients should be given access to information and education about the objectives of treatment and the importance of changes in lifestyle, exercise, pacing of activities, weight reduction, and other measures

The initial focus should be on self-help and patient-driven treatments and on adherence to the regimens, including regular phone contact

Patients may benefit from referral to a physical therapist for evaluation and instruction in appropriate exercises to reduce pain, improve functional capacity, and provision of walking aids

Patients should be encouraged to undertake, and continue to undertake, regular aerobic, muscle strengthening, and range of motion exercises. For patients with symptomatic hip OA, exercises in water can be effective

Patients with hip and knee OA, who are overweight, should be encouraged to lose weight and maintain their weight at a lower level

Patients should be given instruction in the optimal use of a cane or crutch in the contralateral hand with frames or wheeled walkers for those with bilateral disease

In patients with knee OA and mild/moderate varus or valgus instability, a knee brace can reduce pain, improve stability, and diminish the risk of falling

Patients should receive advice concerning appropriate footwear and insoles

Thermal modalities, TENS, and acupuncture may be effective for relieving symptoms

Pharmacological

Acetaminophen/paracetamol (up to 4g/day) can be an effective initial oral analgesic for treatment of mild to moderate pain

NSAIDs should be used at the lowest effective dose and their long-term use should be avoided if possible.

In patients with increased gastrointestinal risk, either a COX-2 selective agent or a non-selective NSAID with co-prescription of a proton pump inhibitor or misoprostol for gastroprotection may be considered, but NSAIDs, including both non-selective and COX-2 selective agents, should be used with caution in patients with cardio-vascular risk factors

Topical NSAIDs and capsaicin can be effective as adjunctives and alternatives to oral analgesic/anti-inflammatory agents in knee OA

IA injections with corticosteroids can be used in patients have moderate to severe pain not responding satisfactorily to oral agents or in patients with an effusion due to knee OA or other signs of local inflammation

IA injections with hyaluronate may be useful in patients with knee or hip OA

Treatment with glucosamine and/or chondroitin sulphate may provide symptomatic benefit in patients with knee OA. If no response is apparent within 6 months treatment should be discontinued. Diacerein may have structure-modifying effects in patients with symptomatic OA of the hip

The use of weak opioids and narcotic analgesics can be considered for the treatment of refractory pain Non-pharmacological therapies should be continued in such patients and surgical treatments should be considered