Osteoarthritis Drug Summary

Drug	Dosage	Remarks
Anilide
Paracetamol1 (Acetaminophen)	325 mg-1 g PO 4-6 hourly Extended release: 1.33 g PO 8 hourly Max dose: 4 g/day or 300-450 mg IV 4 hourly	Adverse Reactions Oral route: Dermatologic effect (rash); Metabolic effects (may increase uric acid, glucose); Hematologic effects (anemia, neutropenia); Hepatic effects (increase bilirubin, alkaline phosphatase); Other effects (nephropathy, hypersensitivity reactions) IV route: GI effects (nausea/vomiting, constipation); CV effects (edema, hypo/hypertension); CNS effects (headache, insomnia, agitation); Other effects (pruritus, rash, hypoalbuminemia, hypokalemia, anemia) Special Instructions Avoid use in patients with severe or active hepatic disease Use with caution in patients with chronic malnutrition, alcoholic liver disease, G6PD deficiency, severe renal impairment
Salicylic Acid & Derivatives
Aspirin (Acetylsal acid, Acetylsalicylic acid)	Initial dose: 4-8 g/day PO in divided doses Maintenance dose: 3.6-5.4 g/day	Adverse Reactions GI effects (nausea/vomiting, dyspepsia, ulceration, hematemesis); Hematologic effects (iron-deficiency anemia after long-term use, hypoprothrombinemia); Dermatologic effects (urticaria, angioedema); Hypersensitivity reactions (bronchospasm, dyspnea); Other effect (hepatotoxicity) Salicylism (dizziness, tinnitus, deafness, sweating, nausea/vomiting, headache, confusion) may occur after repeated use of large doses Special Instructions May be given with food to decrease GI effects Avoid use in patients with hemophilia or other hemorrhagic disorders, history of allergy to other NSAIDs, severe renal or hepatic impairment, pregnancy (especially third trimester) Use with caution in patients prone to dyspepsia, with gastric ulcer, asthma or allergic disorders, renal or hepatic impairment, dehydration, uncontrolled hypertension, G6PD deficiency, DM Aspirin should be stopped several days prior to scheduled surgery
Salsalate (Salicyl salicylate)	Initial dose: Up to 3 g/day PO in divided doses Maintenance dose: 2-4 g/day

¹Combinations with various analgesics are available. Please see the latest MIMS for specific formulations and prescribing information.

Drug	Available Strength	Dosage	Remarks
Other Agents Used as Local Anesthetics
Capsaicin	0.0125% gel 0.025% cream, gel, lotion 0.075% cream, lotion	Apply 6-8 hourly	Adverse Reactions Local effects (erythema, pain, dryness, pruritus, papules, edema, swelling); CV effect (hypertension); GI effects (nausea/vomiting); Respiratory effects (nasopharyngitis, sinusitis, bronchitis) Special Instructions Use with caution in patients with uncontrolled hypertension, history of cardiovascular or cerebrovascular events Should not be applied to broken or irritated skin Treated area should not be exposed to heat or direct sunlight

Drug	Dosage	Remarks
Natural Opium Alkaloids
Dihydrocodeine tartrate	30 mg PO 4-6 hourly Max dose: 60 mg/dose	Adverse Reactions GI effects (nausea/vomiting, constipation, dry mouth); CNS effects (drowsiness, confusion, dizziness, headache, changes in mood); CV effects (bradycardia, tachycardia, palpitations) Large doses may cause respiratory depression/failure, hypotension, deepening coma, renal failure Special Instructions Avoid use in patients with acute respiratory depression, obstructive airway disease, acute alcoholism, convulsive disorder, head injuries, increased intracranial pressure, at risk of paralytic ileus, or in patients who require mental alertness (eg driving, operating machines) Use with caution in patients with hypothyroidism, adrenocortical insufficiency, asthma, renal or hepatic impairment, prostatic hyperplasia, hypotension, shock, inflammatory or obstructive bowel disease, myasthenia gravis Oxycodone: Contraindicated for use in patients <18 years old
Oxycodone	5 mg PO 4-6 hourly May increase when necessary Extended release:  5-10 mg PO 12 hourly Max dose: 400 mg/day Opioid-tolerant: 60-80 mg PO 12 hourly Opioid-naive: 10 mg PO 12 hourly
Other Opioid
Tramadol	50-100 mg PO 4-6 hourly Max dose: 400 mg/day

*Combinations with various analgesics are available. Please see the latest MIMS for specific formulations and prescribing information.

Drug	Dosage	Remarks
Betamethasone Na phosphate/ Betamethasone acetate	Small joints: 0.25-0.5 mL IA Medium joints: 0.5-1 mL IA Large joints: 1-2 mL IA	Adverse Reactions Local effects (post-injection flare, thrombophlebitis, sterile abscess) Special Instructions Systemic absorption should always be considered Use with caution in patients with preexisting psychiatric conditions, heart failure, DM, GI diseases, hepatic impairment including cirrhosis, myasthenia gravis, cataracts and/or glaucoma, osteoporosis, renal impairment, history of seizure disorder, thyroid disease, following acute MI Consider location and size of joint when administering repeat doses
Dexamethasone	Small joints: 0.8-1 mg IA Large joints: 2-4 mg IA
Hydrocortisone	5-50 mg IA
Methylprednisolone1	Small joints: 4-10 mg IA Medium joints: 10-40 mg IA Large joints: 20-80 mg IA Interval of >1-5 weeks
Prednisolone	Small joints: 5-10 mg IA Medium joints: 10-25 mg IA Large joints: 25-50 mg IA
Triamcinolone acetonide	Small joints: 2.5-5 mg IA Max dose: 10 mg IA Large joints: 5-15 mg IA Max dose: 40 mg IA Extended release: 32 mg IA single dose to the knee
Triamcinolone hexacetonide	Small joints: 2-5 mg IA Medium joints: 5-10 mg IA Large joints: 10-20 mg IA

¹Combination with Lidocaine is available. Please see the latest MIMS for specific formulations and prescribing information.

Drug	Dosage	Remarks
Duloxetine	Initial dose: 30 mg PO 24 hourly for 1 week Maintenance dose: 60 mg PO 24 hourly Max dose: 60 mg PO 24 hourly	Adverse Reactions GI effects (nausea, dry mouth); CNS effects (headache, somnolence, dizziness); Psychiatric effects (insomnia, agitation, anxiety, abnormal dreams); CV effect (palpitations); Hepatic effects (increased alkaline phosphatase, aspartate aminotransferase, alanine transaminase, liver injury); GU effects (abnormal orgasm, decreased libido, erectile dysfunction, gynecological hemorrhage, urinary frequency) Special Instructions Instruct patients to swallow whole; do not crush, chew, open capsule or mix with food or liquids Avoid use in patients with narrow-angle glaucoma and/or increased intraocular pressure Use with caution in patients with history of mania, bipolar disorder, depression, seizures, hypertension, renal impairment, hyponatremia, and in patients taking anticoagulants

Drug	Dosage	Remarks
Acetic Acid Derivatives
Aceclofenac1	100 mg PO 12 hourly Controlled release: 200 mg PO 24 hourly	Adverse Reactions GI effects (nausea, GI discomfort, diarrhea, peptic ulceration, GI bleeding); CNS effects (headache, vertigo, dizziness, nervousness, tinnitus, depression, drowsiness, insomnia); Hypersensitivity reactions (angioedema, bronchospasm, rashes, Stevens-Johnson syndrome occur rarely); Hematologic effects (anemia, thrombocytopenia, neutropenia); Other effects (hepatotoxicity, nephrotoxicity, hematuria, fluid retention, photosensitivity, pancreatitis) Coxibs have lesser GI effects Special Instructions May be given with food to decrease GI effects Avoid use in patients with active peptic ulceration, severe heart failure, history of allergy to Aspirin or other NSAIDs Coxibs should not be used in patients with moderate heart failure, ischemic heart disease, peripheral arterial disease, cerebrovascular disease Use with caution in patients with hypertension, infections, asthma or allergic disorders, hemorrhagic disorders, hepatic or renal impairment Coxibs should be used with caution in patients with left ventricular failure, edema, history of cardiac failure, with risk factors for developing heart disease
Acemetacin	60-180 mg/day PO in 1-3 divided doses Extended release:  90 mg PO 24 hourly May be increased to 90 mg PO 12 hourly if necessary
Diclofenac2	35 mg PO 8 hourly or 50 mg PO 8-12 hourly Delayed release: 50-150 mg/day PO in 2-3 divided doses Extended release: 75 mg PO 12-24 hourly or 100 mg PO 24 hourly Max dose: 150 mg/day
Etodolac	600 mg-1 g/day PO in divided doses Extended release: 400 mg-1 g PO 24 hourly
Indometacin (Indomethacin)	25-50 mg PO 6-12 hourly Max dose: 150-200 mg/day in divided doses
Proglumetacin	Initial dose: 450-600 mg/day PO divided 12 hourly Maintenance dose: 300-450 mg/day divided 12 hourly
Sulindac	150-200 mg PO 12 hourly Max dose: 400 mg/day
Tolmetin	Initial dose: 400 mg PO 8 hourly Maintenance dose: 600 mg-1,800 mg/day in 3 divided doses
Coxibs
Celecoxib	200 mg PO 24 hourly or divided 12 hourly May increase to 200 mg PO 12 hourly Max dose: 400 mg/day
Etoricoxib	30-60 mg PO 24 hourly
Fenamic Acid Derivative
Mefenamic acid	500 mg PO 8 hourly or Initially 500 mg PO, followed by 250 mg PO 6 hourly as needed
Oxicam Derivatives
Lornoxicam	12-16 mg/day PO in 2-3 divided doses
Meloxicam	7.5-15 mg PO 24 hourly Max dose: 15 mg/day
Piroxicam3	10-40 mg PO 24 hourly
Tenoxicam	20 mg PO 24 hourly
Propionic Acid Derivatives
Dexibuprofen	600-900 mg PO 24 hourly in 2-3 divided doses Max dose: 1,200 mg/day or 400 mg/dose
Dexketoprofen	12.5 mg PO 4-6 hourly or 25 mg PO 8 hourly Max dose: 75 mg/day
Fenbufen	300 mg PO in the morning and 600 mg PO at bedtime
Fenoprofen	300-600 mg PO 6-8 hourly Max dose: 3.2 g/day
Flurbiprofen	150-200 mg/day PO in divided doses Max dose: 300 mg/day in divided doses
Ibuprofen3	200-800 mg PO 6-8 hourly Max dose: 3.2 g/day Modified-release: Up to 1.6 g/day If needed, may further increase to 2.4 g/day in 2 divided doses
Ketoprofen	Immediate release: 25-50 mg PO 6-12 hourly or 75 mg PO 8 hourly Max dose: 300 mg/day PO in divided doses Extended release: 100-200 mg PO 24 hourly Max dose: 200 mg/day
Loxoprofen	60 mg PO 8 hourly
Naproxen3	250-500 mg PO 12 hourly or 275-550 mg PO 12 hourly Delayed release: 375-500 mg PO 12 hourly Extended release: 750-1,000 mg PO 24 hourly Max dose: 1.5 g/day for limited periods of up to 6 months
Tiaprofenic acid	200 mg PO 8 hourly
Salicylic Acid & Derivative
Diflunisal	Initial dose: 500 mg-1 g/day PO in 2 divided doses Max dose: 1.5 g/day
Other NSAIDs
Nabumetone	500 mg-1 g PO 24 hourly at bedtime May take additional 500 mg-1 g in the morning if needed Max dose: 2 g/day in 1-2 divided doses
Nimesulide	100-200 mg PO 12 hourly

¹Combination with Paracetamol is available. Please see the latest MIMS for specific formulations and prescribing information.
²Combination with Misoprostol is available. Please see the latest MIMS for specific formulations and prescribing information.
³Various combination preparations are available. Please see the latest MIMS for specific formulations and prescribing information.

Drug	Available Strength	Dosage	Remarks
Diclofenac Na	25 mg/mL, 75 mg/3 mL	1 amp/day deep IM in upper outer gluteal quadrant May be increased to 2 amp in severe cases Max dose: 150 mg/day Max duration: 2 days	Adverse Reactions GI effects (nausea/vomiting, gastric ulceration, GI distress, abdominal pain, occult GI bleeding); Other effects (edema, skin rashes, dizziness, headache) Special Instructions Avoid use in patients with known hypersensitivity to the drug or any component of the formulation, including those in whom attacks of asthma, angioedema, urticaria, or rhinitis have been precipitated by Aspirin or any other NSAID, high doses for >4 weeks in patients with established CV disease, uncontrolled hypertension, peptic ulcer Use with caution in patients with symptoms of GI disease, history suggestive of GI ulcerative colitis, Crohn's disease, preexisting dyshemopoiesis or blood coagulation disorders, hepatic, cardiac or renal impairment
Ketoprofen	50 mg/mL	50 mg IM 6-8 hourly Max dose: 200 mg/day
	100 mg/2 mL	1-2 mL IM 4 hourly Max dose: 4 mL/day
Piroxicam	20 mg/mL	40 mg IM 24 hourly for the first 2 days of serious pain Long-term therapy: 10-20 mg/day
Tenoxicam	20 mg powder for injection	20 mg IM/IV as single daily dose for 1-2 days

Drug	Available Strength1	Dosage	Remarks
Diclofenac	0.1% gel; 1% gel	Apply 2-4 g 6-8 hourly	Adverse Reactions May cause local effects (pruritus, rash, contact dermatitis, dry skin, pain, exfoliation, paresthesia, alopecia, edema, photosensitivity) Trolamine salicylate may cause mild irritation or erythema of the skin which are its desired effects Special Instructions Avoid use in patients with known hypersensitivity to the drug or any component of the formulation, including those in whom attacks of asthma, angioedema, urticaria, or rhinitis have been precipitated by Aspirin or any other NSAID Do not apply to non-intact or damaged skin (eg exudative dermatitis, eczema, infected lesions, burns or wounds) Discontinue Trolamine salicylate use if irritation worsens or persists for >7 days
	Extra 1% gel	Apply 2-4 g 6-8 hourly
	1.16% cool gel	Apply to affected areas 6-8 hourly
	1.17% creamagel	Apply to affected areas 6-12 hourly
	1% emulgel	Apply to affected areas 6-8 hourly
	23.2% emulgel	Apply to affected areas 12 hourly
	1% foam	Apply thinly to affected areas 6-8 hourly
	1% lotion	Apply to affected areas 8 hourly
	1% patch	Apply 1 patch 12-24 hourly
	1% spray	Spray on affected area 6-8 hourly
	180 mg plaster	Apply 1-2 plasters 24 hourly
	100 mg suppository	Apply 1 suppository at night
Esflurbiprofen	40 mg patch	Apply to affected area 24 hourly Max dose: 2 patches/day
Etofenamate	5% gel	Apply 5-10 cm 6-8 hourly
	1%, 5% spray	Spray 7 times (18.4 mg) on affected area 4-8 hourly
Flurbiprofen	40 mg plaster	Apply 1 sheet 12 hourly
Ibuprofen	5% gel	Apply 50-125 mg (4-10 cm) 4-6 hourly
Indometacin (Indomethacin)	8 mg/mL spray	Spray on affected area 3-5 times daily Max dose: 25 mL/day
	10 mg/mL spray	Spray on affected area 3-5 times daily
	1% cream	Massage 0.5-1.5 inches to affected area 5-8 hourly
Ketoprofen	20 mg (2%), 40 mg patch	Apply 24 hourly
	2.5% gel	Apply 6-24 hourly
	30 mg plaster	Apply 1 plaster 12 hourly
	100 mg suppository	As monotherapy: 1 supp 12 hourly In combination with oral prep:1 supp at bedtime
Loxoprofen	100 mg patch	Apply 1 patch to affected area 24 hourly
Nimesulide	10 mg/g gel	Apply to affected areas 8-12 hourly
Piroxicam	0.5% gel	Rub 1-3 g (or 1.5-4.5 cm) 6-8 hourly
	48 mg patch	Apply 1 patch 48-72 hourly
Trolamine salicylate (Triethanolamine salicylate)	12% gel	Apply to affected areas 6-8 hourly

¹Various strengths are available. Please see the latest MIMS for specific formulations and prescribing information.

Drug	Dosage	Remarks
Hylan G-F 20	Knee OA: 16 mg IA once weekly for 3 weeks or 48 mg IA as a single dose Hip, ankle, shoulder OA: Initially 16 mg IA, second injection may be administered after 1-3 months	Adverse Reactions Local effects (injection site bruising, erythema, pain, swelling, pruritus); Musculoskeletal effect (arthralgia) Special Instructions Remove effusion, if present, prior to injection Do not inject extra-articularly or into synovium Avoid use in patients with joint infections, skin diseases at injection site Use with caution if venous or lymphatic stasis is present in the leg Avoid strenuous activities for 48 hours after injection
Na hyaluronate (Hyaluronic acid)1	24 mg IA once weekly for 2 weeks or 20-25 mg IA once weekly for 3-5 weeks or up to 30 mg IA once weekly for 3-4 weeks May be repeated after 6 months depending on patient's condition or 60 mg IA as a single dose
Polynucleotides	Three IA injection of 2 mL (20 mg/mL) in the joint to be treated Time interval between each injection is 1-3 weeks	Adverse Reactions Local effects (burning sensation, erythema, pain, swelling) Special Instructions Remove effusion, if present, prior to injection Do not inject extra-articularly or into synovium Avoid use in patients with joint infections, skin diseases at injection site, or history of allergy to products originating from fish Use with caution if venous or lymphatic stasis is present in the leg Avoid strenuous activities for 48 hours after injection

¹Various combination preparations are available. Please see the latest MIMS for specific formulations and prescribing information.

Drug	Dosage	Remarks
Chondroitin/Glucosamine1	Caplet: Chondroitin 200 mg/Glucosamine 250 mg 3-6 caplet PO 24 hourly Tab: Chondroitin 300 mg/Glucosamine 500 mg 1 tab PO 8 hourly Chondroitin 400 mg/Glucosamine 500 mg 1 tab PO 6-12 hourly Chondroitin 400 mg/Glucosamine 750 mg 2 tab PO 24 hourly Powder for oral liquid: Chondroitin 600 mg/Glucosamine 750-942 mg 2 sachets 24 hourly or in 2 divided doses Chondroitin 1,200 mg/Glucosamine 1,500-1,884 mg1 sachet 24 hourly	Adverse Reactions GI effects (dyspepsia, nausea, flatulence, constipation, diarrhea); CNS effects (headache, somnolence); Other effects (rash, pruritus, erythema, peripheral edema, tachycardia) Special Instructions Use with caution in patients with history of bleeding, hemostatic disorders, or drug-related hemostatic problems Use caution with concurrent therapy with anticoagulants or antiplatelet agents
Diacerein	50 mg PO 24 hourly at night for the first month followed by 50 mg PO 12 hourly	Adverse Reactions GI effects (diarrhea, nausea/vomiting, epigastric pain) Special Instructions Take with meals Avoid use in patients with inflammatory bowel disease (eg Crohn's disease, ulcerative colitis), intestinal obstruction, severe hepatic and renal impairment
Glucosamine1	Mild-moderate symptoms: 500 mg PO 12 hourly for ≥6 weeks Severe symptoms: Initial dose: 500 mg PO 8 hourly for ≥8 weeks Maintenance dose: 500 mg PO 12 hourly for 3-4 months Sustained-release: 1,500 mg PO 24 hourly for 3 months As glucosamine sulfate tab/powder for oral solution: 1,500 mg PO 24 hourly as a single dose or in 2-3 divided doses	Adverse Reactions Occasional reports of mild GI discomfort or stomach upset May cause drowsiness, somnolence, or insomnia Special Instructions Take with meals Effervescent tab: Dissolve in at least 100 mL of water; powder for oral solution: Dissolve in at least 250 mL of water Avoid use in patients with allergy to shellfish; active bleeding (eg peptic ulcer, intracranial bleeding) Use with caution in patients with DM, renal impairment, history of bleeding, hemostatic disorders, or drug-related hemostatic problems Use caution with concurrent therapy with anticoagulants or antiplatelet agents, in patients who require mental alertness (ie driving or operating machines)
Undenatured type II collagen (UC-II)/ Boswellia serrata gum extract (Aflapin)	Undenatured type II collagen (UC-II) 40 mg/Boswellia serrata gum extract (Aflapin) 100 mg per cap 1 cap PO 24 hourly for 3-6 months	Special Instructions Contraindicated in patients with hypersensitivity to the active substances or to any of the excipients Not recommended for pregnancy and lactation
Unsaponifiable avocado and soybean oil	300 mg PO 24 hourly for 3-6 months	Adverse Reactions Rarely GI, hepatobiliary and immune system disorders Special Instructions Should be taken with food Avoid use in patients <18 years old

¹Various combination preparations are available. Please see the latest MIMS for specific formulations and prescribing information.

Drug	Available Strength	Dosage	Remarks
Cetylated fatty acids (CFA)	7.5% cream	Apply cream to affected joints 12 hourly	Special Instructions Apply on intact skin Use with caution in pregnant and lactating patients and in children <12 years old
Glucosamine sulfate potassium chloride1	3% cream	Apply cream to affected joints 8-24 hourly	Special Instructions Apply on intact skin
Phosphatidylcholine (Soy phosphatidylcholine, Phosphatidyl choline)	Gel	Apply gel to affected joints 12 hourly	Adverse Reactions There have been reports of minor skin irritations Special Instructions Apply on dry skin then allow to dry Avoid applying on open wounds and infected skin Do not apply on the eyes, nose or mouth Use with caution in pregnant and lactating patients and in children

¹Various combination preparations are available. Please see the latest MIMS for specific formulations and prescribing information.

Drug	Dosage	Remarks
Hydrolyzed collagen1 (Collagen hydrolysate, Collagen peptide)	1,200 mg PO 24 hourly at bedtime	Special Instructions Should be taken on an empty stomach Contraindicated in patients with liver or kidney disease, low protein diet; pregnancy and lactation

¹Various combination preparations are available. Please see the latest MIMS for specific formulations and prescribing information.

All dosage recommendations are for non-pregnant and non-breastfeeding women and non-elderly adults with normal renal and hepatic function unless otherwise stated. 
Not all products are available or approved for above use in all countries. 
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs. 
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.