acetaminophen, OTC NSAIDs, and/or OTC nutritional supplements (e.g., chondroitin sulfate, glucosamine), the TEP conditionally recommends that health care providers can use acetaminophen, oral or topical NSAIDs, tramadol, or intraarticular corticosteroid injections (Table 4). The TEP conditionally recommends that health care providers do not use nutritional supplements (e.g., chondroitin sulfate, glucosamine) or topical capsaicin. If the health care provider chooses to initiate acetaminophen in the full dosage up to 4,000 mg/day, the patient should be counseled to avoid all other products that contain acetaminophen, including OTC cold remedies as well as combination products with opioid analgesics. We have no recommendations regarding the use of intraarticular hyaluronates, duloxetine, and opioid analgesics No strong recommendations were made for the initial pharmacologic management of knee osteoarthritis (OA). For patients who have an inadequate response to initial pharmacologic management, please see the Results for alternative strategies. NSAIDs = nonsteroidal antiinflammatory drugs. If the patient does not have a satisfactory clinical response to full-dose acetaminophen, then the TEP strongly recommends the use of oral or topical NSAIDs or intraarticular corticosteroid injections (18, 19). Health care providers should not use oral NSAIDs in patients with contraindications to these agents and should be aware of the warnings and precautions associated with the use of these agents. Furthermore, for persons age ≥75 years, the TEP strongly recommends the use of topical rather than oral NSAIDs (28). In this scenario, the TEP conditionally recommends the use of tramadol, duloxetine, or intraarticular hyaluronan injections. If the patient has a history of a symptomatic or complicated upper GI ulcer but has not had an upper GI bleed in the past year and the practitioner chooses to use an oral NSAID, the TEP strongly recommends using either a cyclooxygenase 2 (COX-2) selective inhibitor or a nonselective NSAID in combination with a proton-pump inhibitor; there was no preference expressed between these choices (29). In the clinical scenario where the above patient has had an upper GI bleed within the past year and the practitioner still chooses to use an oral NSAID, the TEP strongly recommends using a COX-2 selective inhibitor in combination with a proton-pump inhibitor. Subsequent to the initial meeting of the TEP, Latimer and colleagues reported that the addition of a proton-pump inhibitor to either a nonselective or COX-2 selective NSAID is cost effective given the evolving evidence base for efficacy and reductions in price (30). Therefore, whenever an NSAID is used for the chronic management of patients with knee or hip OA, the practitioner should consider adding a proton-pump inhibitor to reduce the risk of development of symptomatic or complicated upper GI events. In the clinical scenario where the patient with OA is taking low-dose aspirin (≤325 mg per day) for cardioprotection and the practitioner chooses to use an oral NSAID, the TEP strongly recommends using a nonselective NSAID other than ibuprofen in combination with a proton-pump inhibitor. This recommendation is based, in part, on the FDA warning that the concomitant use of ibuprofen and low-dose aspirin may render aspirin less effective when used for cardioprotection and stroke prevention because of a recognized