Match the NSAID to the patient's risk, not the other way round. Review cardiovascular, renal, GI and bleeding risk before every NSAID script. Steroid injections help short-term but are capped, and orthopaedic referral can be transformative once conservative care has genuinely failed.
Oral NSAID risk by patient group
- Low risk: naproxen 250–500mg BD commonly preferred; avoid long courses; add PPI if age >65 or course >2 weeks.
- CV risk / IHD: naproxen has the more favourable CV profile of the NSAIDs; avoid diclofenac and COX-2 selective agents; add PPI.
- GI risk (prior ulcer, age >65): COX-2 selective agent + PPI commonly preferred; avoid long-term non-selective NSAID.
- Renal impairment (eGFR <60): avoid all NSAIDs where possible — oral and topical both carry renal risk in this group.
- Anticoagulated: topical NSAID only where possible; if oral is unavoidable, add a PPI and review closely.
Intra-articular steroid injection. Indications: knee OA with effusion or flare; shoulder, base-of-thumb or hip OA (image-guided). Typical agent: methylprednisolone acetate with local anaesthetic, or triamcinolone — confirm current product and dose at eTG. Frequency: commonly capped at 3–4 injections per joint per year — more frequent dosing has been associated with accelerated cartilage loss. Effect: symptomatic improvement over roughly 2–12 weeks — a bridge to other interventions, not a standalone fix. Contraindications: active infection, septic joint, uncontrolled diabetes (transient glucose rise).
When to refer orthopaedics
- End-stage symptoms: severe pain, night pain or functional loss despite optimal conservative treatment.
- Imaging-confirmed: severe radiographic OA (KL grade 3–4) with a matching clinical picture.
- TKR/THR candidate: failed 3–6 months conservative treatment, age- and comorbidity-adjusted.
- Red flags (urgent): locked knee, a mechanical block, or suspected septic arthritis.
Patient resources & MBS planning
MyJointPain (myjointpain.org.au) and the GLA:D Australia program (gladaustralia.com.au) for evidence-based exercise and education. Up to 5 Medicare-subsidised physiotherapy visits per calendar year are available under a GP Chronic Condition Management Plan (replacing the former EPC arrangements) — confirm current item numbers at mbsonline.gov.au. Image only if red flags or a surgical referral is being planned.
Safety
- Review CV, GI, renal and bleeding risk before every NSAID prescription — match the agent to the risk, not the reverse.
- Cap intra-articular steroid at 3–4 injections per joint per year — more frequent dosing has been linked to accelerated cartilage loss.
- Avoid all NSAIDs where possible if eGFR <60 — oral and topical both carry renal risk in this group.
Red flags / refer
- Locked knee, a mechanical block, or suspected septic arthritis → urgent orthopaedic referral, same day.
- Severe pain, night pain or functional loss despite optimal conservative treatment, or a TKR/THR candidate who has failed 3–6 months conservative care → orthopaedic referral.
- Severe radiographic OA (KL grade 3–4) with a matching clinical picture and ongoing symptoms → orthopaedic referral.
PA-03B v1.0 · Reviewed Jun 2026 · Review Jun 2027
For health-professional use. Framework: RACGP Guideline for the Management of Knee and Hip Osteoarthritis, OARSI. Companion sheet: PA-03 OA Treatment Pathway. Doses are a guide only — confirm current dosing at eTG.
