Q: What is new about these recommendations?
These are the first national guidelines supplying evidence-based recommendations for improving life for patients with osteoarthritis (OA). They are patient-centred, and outline lifestyle changes and pharmaceutical agents recommended to help ease OA symptoms.
NICE delivers clear advice on assessment, treatment and referral, and it means that the common misperception that nothing can be done for OA is no longer correct. It is good news for patients, and clarifies the position for GPs, heralding a move to active OA management.
Q: If I follow the NICE guidelines, how will I manage OA patients?
You assess patients holistically, offer all patients with clinically symptomatic arthritis advice on core treatments, and then prepare a management plan with them. Care is to be patient-centred, taking into account individual needs and preferences, offering evidence-based information to guide patients' decision-making.
Q: What should I consider in the 'holistic' assessment?
You'll evaluate the patient's existing knowledge of OA, their concerns and expectations, along with the effect of OA on their function, quality of life, work, mood, sleep, relationships and leisure activities, plus their pain levels and any compounding co-morbidities.
Also consider whether adjustments to the workplace are advisable, whether the patient is isolated, and whether there is a carer or support network. As part of active management, periodic reviews are recommended, tailored to the individual.
Q: Which core treatments are recommended?
Particularly innovative is the emphasis on providing information to help your patient understand the condition, and there is a predictable focus on weight management and on exercise.
The recommended core treatments are:
- Accurate verbal and written information.
- Aerobic exercise and muscle strengthening therapy, irrespective of age, other conditions, pain severity or disability.
- Weight loss interventions for overweight and obese patients.
As an adjunct to core treatment, NICE recommends topical NSAIDs are offered for knee and hand OA.
Q: Do the guidelines give us a steer on the use of COX-2 inhibitors?
NICE at last gives GPs clear guidance on selective COX-2 inhibitors, after their earlier withdrawal amid concerns of MI risk.
Now (other than etoricoxib 60mg) they're back in the black bag, alongside standard NSAIDs, provided you prescribe with a proton-pump inhibitor, at the lowest effective dose, and for a short time.
Of course, you will always assess patient risk factors - cardio-renal, liver and GI - however, if a patient needs to take low-dose aspirin it is recommended you consider other analgesics before an NSAID or COX-2 inhibitor.
Q: What else is important in the prescribing recommendations?
Paracetamol - in regular dosing if required - and/or topical NSAIDS should be offered before considering oral NSAIDs, COX-2 inhibitors, other than etoricoxib 60mg, or opioids.
Topical NSAIDs or topical capsaicin are recommended for knee and hand arthritis. You can offer intra-articular corticosteroid injections where pain is moderate to severe.
Q: Is there anything I should not prescribe under the new guidelines?
NICE specifically recommends that you do not prescribe: rubefacients; intra-articular hyaluronan injections; electro-acupuncture or chondroitin or glucosamine products.
Q: What is the guidance on referral for surgery?
Joint replacement surgery should be considered for OA patients not sufficiently managed on other treatments and whose joint pain, stiffness and reduced function has a 'substantial impact' on their quality of life. Referral should be made before the patient experiences prolonged, established functional limitation and severe pain. Importantly, the guidelines state that patient-specific factors like age, obesity, smoking and gender should not be barriers to referral.
It is worth noting that waiting times have fallen greatly for joint replacement, and you can begin preparing the patient for assessment and treatment within a couple of months.
There are long-held expectations in patients that you still have to wait a couple of years to get the operation. This results in patients often choosing not to proceed because they either have practical things to arrange (such as work, booked holidays, weight to lose) or psychologically they just need more time to prepare. Had the initial conversation with the GP prepared them from the outset, they might have been ready to accept the offer of early treatment.
Q: The guidelines make an issue of giving information. Where do I find it?
The NICE guidelines include contacts for research charity Arthritis Research Campaign and for the patient support organisation, Arthritis Care.
Arthritis Care runs free self-management courses on understanding arthritis and challenging pain, and provides free information booklets. Patients can download fact sheets from the Arthritis Care website. They also run a free helpline which is staffed 10am-4pm weekdays by trained counsellors.
Q: Where can I view the complete guidance?
Dr Amin is a GP in Enfield, Middlesex, and has volunteered his services as a medical adviser to Arthritis Care since 2005.