MIMS Summary: NICE guidance on osteoarthritis

The new guideline provides recommendations for the optimum care of adults with osteoarthritis (OA) including a number that are not currently routine practice for many clinicians.

OA is the most common form of arthritis and a leading cause of pain and disability. A complex disorder with multiple risk factors, it shows extreme variability in clinical presentation and outcome between patients and at different joints in the same patient.

 

KEY RECOMMENDATIONS FOR PRIMARY CARE

  • Adopt a holistic approach to assessment, taking into account the patient’s function, quality of life, occupation, mood, relationships and leisure activities.
  • Agree a management plan emphasising the core treatments and review regularly.

Core treatments

  • Access to appropriate information to enhance understanding of the condition.
  • Activity and exercise including local muscle strengthening and general aerobic fitness.
  • Weight loss if the patient is overweight or obese.

Pharmacological adjuncts to core treatments

  • Paracetamol – regular dosing may be required.
  • For knee or hand OA, consider topical NSAIDs or capsaicin.
  • Consider topical NSAIDs and/or paracetamol before oral NSAIDs, COX-2 inhibitors or opioids.
  • If paracetamol or topical NSAIDs provide insufficient pain relief, consider adding:
    – an opioid analgesic (assess the risks and benefits, particularly in the elderly)
    – an oral NSAID/COX-2 inhibitor (or use as substitute instead of add-on)
  • When an oral NSAID or COX-2 inhibitor is indicated:
    - first choice is a standard NSAID or a COX-2 inhibitor (but not etoricoxib 60mg)
    - co-prescribe with a proton-pump inhibitor (choose agent with lowest cost)
    - prescribe at the lowest effective dose for the shortest period of time
    - consider individual’s risk factors in light of potential GI, liver and cardio-renal toxicity.
  • Consider intra-articular corticosteroid injections when pain is moderate to severe.

Non-pharmacological adjuncts to core treatments

  • Application of heat or cold to site of pain.
  • Transcutaneous electrical nerve stimulation (TENS).
  • Manipulation and stretching, particularly for hip OA.
  • Assessment for bracing/joint supports/insoles if biomechanical joint pain/instability.
  • Assistive devices (e.g. walking sticks) if appropriate.

Note: use of rubefacients, intra-articular hyaluronan injections, electro-acupuncture and chondroitin or glucosamine products are not recommended.


Referral

  • Consider referral for joint replacement surgery if the patient has been offered all core treatments, is experiencing joint symptoms with substantial impact on quality of life and is refractory to non-surgical treatment. Refer before there is prolonged and established functional limitation and severe pain.
  • Do not offer referral for arthroscopic lavage and debridement unless the patient has knee OA with a clear history of mechanical locking.

 

The full guideline is available at www.nice.org.uk.

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