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Guidelines for the treatment of osteoarthritis (OA) have several purposes, but a major one relates to its use by regulatory or medical insurance agencies that use it to help guide their response to requests for drugs to treat patients. Data have recently been published which record the efficacy of non-steroidal antiinflammatory drugs (NSAIDs) over paracetamol (acetaminophen) and report patients’ preferences for NSAIDs rather than paracetamol in the treatment of OA. Furthermore, inflammation is a common accompaniment of moderate to severe OA. Therefore it would seem appropriate to consider the use of NSAIDs as the primary treatment in the group of patients with OA with moderate to severe pain or inflammation as part of their disease. The EULAR Guidelines state that paracetamol is the first line of treatment for all patients with OA, despite the recent evidence that NSAIDs are more efficacious than paracetamol and that paracetamol is associated with more gastrointestinal toxicity than was previously thought. Would it not be more appropriate to suggest that patients who have moderate to severe pain and/or OA with inflammatory components be given NSAIDs as the first line of treatment, leaving paracetamol for symptomatic use in those patients with lesser degrees of pain or lack of overt inflammation?