Practice Guidelines

Care and management of osteoarthritis in adults: summary of NICE guidance

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39490.608009.AD (Published 28 February 2008) Cite this as: BMJ 2008;336:502
  1. Philip G Conaghan, professor of musculoskeletal medicine1,
  2. John Dickson, community physician in rheumatology 2,
  3. Robert L Grant, senior technical adviser at National Collaborating Centre for Chronic Conditions, and medical statistician3
  4. on behalf of the Guideline Development Group
  1. 1Section of Musculoskeletal Disease, University of Leeds, Leeds LS7 4SA
  2. 2Redcar and Cleveland Primary Care Trust, Guisborough Primary Care Hospital, Guisborough TS14 6HZ
  3. 3Royal College of Physicians of London, London NW1 4LE
  1. Correspondence to: P Conaghan, Section of Musculoskeletal Disease, Chapel Allerton Hospital, Leeds LS7 4SA p.conaghan{at}leeds.ac.uk

    Why read this summary?

    Osteoarthritis refers to a syndrome of joint pain accompanied by functional limitation and reduced quality of life. It is the most common form of arthritis and one of the leading causes of pain and disability in the United Kingdom. The published evidence for osteoarthritis treatment has many limitations—typically, short duration studies using single drug treatments. However, people with osteoarthritis need to be aware of the treatments that represent core management and of the range of additional treatments available. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the care and management of osteoarthritis in adults.1

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

    Holistic assessment and management of symptomatic osteoarthritis

    • Assess the effect of osteoarthritis on the individual’s function, quality of life, occupation, mood, relationships, and leisure activities.

    • Provide periodic review tailored to an individual’s needs.

    • Formulate a management plan in partnership with the person with osteoarthritis, taking into consideration comorbidities that compound the effect of osteoarthritis.

    • Communicate the risks and benefits of treatment options in ways that can be understood.

    Core treatments

    Provide advice on the following to all people with symptomatic osteoarthritis:

    • Access to appropriate information, oral and written, to enhance understanding of the condition and to counter misconceptions (such as osteoarthritis is inevitably progressive and cannot be treated). [Based on moderate quality evidence from meta-analyses, randomised controlled trials (RCTs), and small observational studies] Good sources of patient information exist online at www.arc.org.uk (Arthritis Research Campaign), www.move.uk.net (Move), and www.arthritiscare.org.uk (Arthritis Care).

    • Activity and exercise, including local muscle strengthening and general aerobic fitness. [Based on moderate quality evidence from RCTs]

    • Interventions to achieve weight loss if person is overweight or obese. [Based on moderate quality evidence from one meta-analysis and one RCT]

    Other treatments can be used as adjuncts to these core treatments (see figure), and a person with osteoarthritis may use several of these treatments. Some treatments will be useful only for certain joints.

    Figure1

    Treatments for osteoarthritis in adults. Starting at the centre and working outwards, the treatments are arranged in the order in which they should be considered, taking into account individuals’ different needs, risk factors, and preferences. The core treatments (centre) should be considered first for every person with osteoarthritis. If further treatment is required, consider the drugs in the second circle before the drugs in the outer circle. The outer circle also shows adjunctive treatments (both non-pharmacological and surgical), which have less well proved efficacy, provide less symptom relief, or have increased risk to the patient compared with those in the second circle

    Adjunct non-pharmacological treatments

    • Agree on self management strategies with the person with osteoarthritis, emphasising the recommended core treatments, especially exercise. [Based on moderate quality evidence from meta-analyses, RCTs, and small observational studies]

    • Target positive behavioural changes as appropriate—such as exercise, weight loss, use of suitable footwear (that is, with shock absorbing properties) [based on high quality evidence from a meta-analysis and RCTs] and pacing (avoiding “peaks” and “troughs” of activities). [Based on low quality evidence from two RCTs]

    • Consider other therapies, such as:

      • -Local heat or cold applications [Based on moderate evidence from a small meta-analysis]

      • -Manipulation and stretching, particularly for osteoarthritis of the hip [Based on moderate quality evidence from RCTs]

      • -Transcutaneous electrical nerve stimulation (TENS) [Based on moderate quality evidence from a meta-analysis and small RCTs]

      • -Assessment for bracing, joint supports, or insoles in those with biomechanical joint pain or instability [Based on moderate quality evidence from a meta-analysis and RCTs]

      • -Assistive devices (for example, walking sticks and tap turners) for those who have specific problems with activities of daily living. [Based on moderate quality evidence from one small RCT and small observational studies] Expert advice may be sought, for example, from occupational therapists or disability equipment assessment centres.

    Electroacupuncture should not be used. [Based on one moderate quality RCT plus cost effectiveness analysis] Insufficient evidence exists (despite RCTs and cost effectiveness analysis) to make a firm recommendation on acupuncture. The use of glucosamine and chondroitin products is not recommended. [Based on high quality evidence from meta-analyses and RCTs, plus cost effectiveness analysis]

    Adjunct pharmacological treatments

    Consider risks and benefits of pharmacological treatments, particularly in elderly people and those with comorbidities.

    • Offer paracetamol for pain relief—regular dosing may be needed. [Based on high quality evidence from meta-analyses and one RCT]

    • For knee and hand osteoarthritis, consider paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) before oral NSAIDs, cyclo-oxygenase-2 (COX 2) inhibitors, and opioids. [Based on high quality evidence from meta-analyses and RCTs]

    • Consider topical capsaicin. [Based on moderate quality evidence from small RCTs]

    • If paracetamol or topical NSAIDs are insufficient for pain relief, then consider adding opioid analgesics [based on high quality evidence from meta-analyses] or substituting with (or in addition to paracetamol) an oral NSAID or COX 2 inhibitor. [Based on high quality evidence from large randomised controlled trials, supplemented by meta-analysis and health economic modelling of cost effectiveness]

    • Use oral NSAIDs or COX 2 inhibitors at the lowest effective dose for the shortest possible period of time. The first choice should be either a COX 2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID. In either case, prescribe these alongside a proton pump inhibitor, choosing the one with the lowest acquisition cost. [Based on high quality evidence from large RCTs plus health economic modelling of cost effectiveness]

    • All oral NSAIDs and COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal, liver, and cardiorenal toxicity; therefore, when choosing the agent and dose, take into account an individual’s risk factors (including age) and consider appropriate assessment and/or ongoing monitoring of these risk factors. [Based on high quality evidence from large RCTs and observational studies]

    • If a person with osteoarthritis needs to take low dose aspirin, consider other analgesics before substituting with or adding an NSAID or COX 2 inhibitor (plus a proton pump inhibitor) if pain relief is ineffective or insufficient. [Based on high quality evidence from large RCTs]

    • Consider intra-articular corticosteroid injections for the relief of moderate to severe pain. [Based on moderate quality evidence from meta-analysis and small RCTs]

    Rubefacients [based on moderate quality evidence from small RCTs] and intra-articular hyaluronan injections [based on high quality evidence from meta-analysis and RCTs, supplemented by cost effectiveness analysis] are not recommended for the treatment of osteoarthritis.

    Referral for surgical interventions

    • Referral for arthroscopic lavage and debridement should not be routinely offered as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (therefore not for reasons such as gelling (stiffness and pain associated with prolonged immobility) “giving way,” or x ray evidence of loose bodies—currently common inappropriate reasons for referral). [Based on moderate quality evidence from small to moderately sized RCTs]

    • Before referring a patient for consideration of joint surgery, ensure that he or she has been offered at least the core treatment options. [Based on the experience of the Guideline Development Group]

    • Consider referral for joint replacement surgery for people with osteoarthritis who have joint symptoms (pain, stiffness, and reduced function) that substantially affect their quality of life and are refractory to non-surgical treatment. [Based on moderate quality evidence from expert opinion papers, one cross sectional study, one observational study, and one observational-correlation study]. Referral should be made before there is prolonged and established functional limitation and severe pain.

    • Patient specific factors (including age, sex, smoking, obesity, and comorbidities) should not be barriers to referral for joint replacement surgery. [Based on moderate quality evidence from large cohort studies]

    • Base decisions about referral thresholds on discussions between patient representatives, referring clinicians, and surgeons, rather than on current scoring tools for prioritisation. [Based on absence of evidence supporting prioritisation tools]

    Overcoming barriers

    Improved understanding, among healthcare professionals and people with osteoarthritis, of the range of treatments available will reduce misconceptions and negativity about osteoarthritis and its treatment. Emphasising the recommended core treatments, other simple, non-pharmacological treatments, and relatively safe agents such as paracetamol and topical NSAIDs will help to reduce drug toxicity and the focus on pharmacological treatments.

    Further information on the guidance

    Methods

    The Guideline Development Group followed standard NICE methodology in the development of this guideline (www.nice.org.uk/page.aspx?o=114219). The group comprised patient and carer representatives and experts in rheumatology, primary care, health services research, physiotherapy, geriatric medicine, health economics, epidemiology, systematic reviews, nursing, and information science. Additional experts were invited to advise the group on acupuncture, communicating risk, occupational therapy, orthopaedic surgery, and podiatry.

    Future research

    The effect size of many individual treatments may be small, and there is a huge need for further research on improving the treatment of osteoarthritis, including improving adherence to treatments, understanding the benefits of treatment in very elderly patients, optimal combinations of existing treatments, predictors of good surgical outcomes, and determining how to treat people with multiple joint pains.

    Footnotes

    • This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they will highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

    • The members of the Guidelines Development Group are Fraser Birrell, consultant rheumatologist, Northumbria Healthcare NHS Trust, and honorary clinical senior lecturer, University of Newcastle upon Tyne; Michael Burke, general practitioner, Merseyside; Philip Conaghan, chairman of the development group, professor of musculoskeletal medicine, University of Leeds, and consultant rheumatologist, Leeds Teaching Hospitals NHS Trust; Jo Cumming, patient and carer representative, London; John Dickson, clinical adviser to the development group, clinical lead for musculoskeletal services, Redcar and Cleveland Primary Care Trust; Paul Dieppe, professor of health services research, University of Bristol; Mike Doherty, head of academic rheumatology, University of Nottingham, and honorary consultant rheumatologist, Nottingham University Hospitals NHS Trust; Krysia Dziedzic, Arthritis Research Campaign senior lecturer in physiotherapy, Primary Care Musculoskeletal Research Centre, Keele University; Roger Francis, professor of geriatric medicine, University of Newcastle upon Tyne; Rob Grant, senior technical adviser, National Collaborating Centre for Chronic Conditions, and medical statistician, Royal College of Physicians of London; Christine Kell, patient & carer representative, County Durham; Nick Latimer, health economist, National Collaborating Centre for Chronic Conditions, and research fellow, Queen Mary University of London; Alex MacGregor, professor of chronic diseases epidemiology, University of East Anglia, and consultant rheumatologist, Norfolk and Norwich University Hospital NHS Trust; Carolyn Naisby, consultant physiotherapist, City Hospitals Sunderland NHS Foundation Trust; Rachel O’Mahony, health services research fellow in guideline development, National Collaborating Centre for Chronic Conditions; Susan Oliver, nurse consultant in rheumatology, Litchdon Medical Centre, Barnstaple; Alison Richards, information scientist, National Collaborating Centre for Chronic Conditions; Martin Underwood, vice-dean, Warwick Medical School. The following experts were invited to attend specific meetings and to advise the development group: Marta Buszewicz, senior lecturer in community based teaching & research, University College London; Alison Carr, lecturer in musculoskeletal epidemiology, University of Nottingham; Mark Emerton, consultant orthopaedic surgeon, Leeds Teaching Hospitals NHS Trust; Edzard Ernst, Laing professor of complementary medicine, Peninsula Medical School; Alison Hammond, Arthritis Research Campaign senior lecturer, Brighton University; Dr Mike Hurley, Reader in Physiotherapy & Arthritis Research Campaign research fellow, King’s College London; Andrew McCaskie, professor of orthopaedics, University of Newcastle upon Tyne; Mark Porcheret, general practitioner research fellow, Keele University; Tony Redmond, Arthritis Research Campaign lecturer in podiatric rheumatology, University of Leeds; Adrian White, clinical research fellow, Peninsula Medical School.

    • Contributors: All authors contributed to the conception and drafting of this article and revising it critically. They have all approved this version.

    • Funding: The National Collaborating Centre for Chronic Conditions was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

    • Competing interests: All authors were members of the Guideline Development Group (PGC chaired the group, JD was the clinical adviser, RLG was the project manager). During the past two years PGC has received travel grants to educational meetings from MSD and honorariums for tutorials (MSD) and been an adviser to Novartis and Bristol Myers Squibb on imaging studies in rheumatoid arthritis. JD has received travel grants from Pfizer, Wyeth, Novartis, and Napp, and honorariums for tutorials from Pfizer and Novartis; he has been on advisory boards for pharmaceutical companies including GSK, Wyeth, and Novartis.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References