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For more information, go to www.arthritisresearchuk.org

NICE work on osteoarthritis

Published on 04 April 2008
Source: Arthritis Today

A doctor checking a patient's blood pressureNew national guidelines on how osteoarthritis should be treated are now in the hands of every GP in the country. Arthritis Today provides a summary.

As anyone who has osteoarthritis can testify, the level of care and service provided by their local general practitioner varies enormously.

It can range from the standard phrase: “It’s your age, go away and live with it,” to the gratuitous handing out of painkillers. Some GPs never even use the term osteoarthritis to describe the condition, just arthritis or joint pain, leaving the patient confused and dissatisfied.

Other, more enlightened doctors and those with a genuine interest in the condition keep up-to-date with the advice and information provided by Arthritis Research UK and other bodies and enthusiastically suggest exercise, weight loss, and self-management to their patients.

This patchiness of care may now become a thing of the past with the issuing in February of a set of national guidelines suggesting best practice for the treatment of osteoarthritis by the National Institute for Health and Clinical Excellence (NICE).

While some of the recommendations appear aspirational rather than practical – has anyone with osteoarthritis ever been offered a self-management plan by the GP for example? – most are extremely sensible and based on solid evidence.

What your GP should discuss with you as part of a self-management plan:

  • exercise 
  • weight loss if you are overweight
  • use of suitable footwear
  • application of heat or cold packs to the skin where it hurts
  • transcutaneous electrical nerve stimulation (TENS) for pain relief

One of the most welcome recommendations focuses on the importance of exercise and maintaining a healthy weight, although the small print of the guidelines don’t specify whether the exercise should be provided by the NHS or if the GP should encourage the patient to make his or her own arrangements.

Another interesting recommendation is the suggestion that topical NSAIDs (creams rubbed into the skin) should be used before tablet forms of the drug, and that topical capsaicin should also be considered. Although it is still unclear whether using topical NSAIDs reduces the incidence of serious NSAID-related side effects, the NICE team says that it seems logical that there would be a reduced risk as the total dose is much smaller.

Probably the most controversial is that the vastly popular glucosamine and chondroitin products should not be recommended. However, the NICE team makes clear that while they do not feel there is enough evidence to warrant the NHS paying for the supplement, it is still worth considering over-the-counter glucosamine sulphate (1,500 mg a day) as it may help relieve pain to a mild degree in some people.

The complicating factor is that the only NHS-prescribed glucosamine product is glucosamine hydrochloride (under the brand name Alateris), and the evidence for this product is also poor. So those patients currently receiving their glucosamine on prescription may have to start buying it themselves.

Chief executive Fergus Logan says: “These new national standards will, we hope, mean that people with osteoarthritis can expect the same uniformly high level of treatment from their GPs and other health professionals.

“For too long patients have been told that nothing can be done about their condition, and that they just have to learn to live with it. But NICE has now made official what we have been telling people for many years – that exercise and weight loss play a major part in treating osteoarthritis effectively. We hope that healthcare professionals now implement these guidelines.”

Professor Philip ConaghanProfessor of musculoskeletal medicine in Leeds Philip Conaghan, who led the NICE team that produced the guidance, agrees that a national audit of GPs would improve implementation.

“While the recommendations don’t contain anything earth-shattering, they provide a standard below which healthcare professionals should not drop,” he says. “They emphasise that the course of osteoarthritis is not inevitably downhill, and that people with osteoarthritis will largely need a combination of approaches, such as muscle-strengthening, appropriate footwear and paracetamol to reduce pain.”

Printed copies of the NICE osteoarthritis patient guide can be ordered from 0845 003 7783 or at emailpublications@nice.org.uk quoting reference N1460.

Read the NICE guidance on osteoarthritis 

Guidelines in a nutshell
There are three core treatments:

  1. appropriate information about the condition
  2. exercise
  3. weight loss if overweight or obese.
  • Exercise should be considered, irrespective of age, other illnesses or conditions, pain or disability, and should include local muscle strengthening and general aerobic fitness. People with osteoarthritis should be supported to lose weight if they are overweight or obese.
    Healthcare professionals should consider offering paracetamol and/or topical NSAIDs for pain relief, in addition to core treatment, to people with knee or hand osteoarthritis. Topical NSAIDs and/or paracetamol (which are safer) should be considered ahead of oral NSAIDs, COX-2 inhibitors or opioids.
  • When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor. In either case, these should be co-prescribed with a proton pump inhibitor (PPI) to protect the stomach.
  • Referral for joint replacement surgery should be considered for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and do not respond to non-surgical treatment.

What’s NOT recommended

  • Glucosamine or chondroitin products. The NICE team says that the evidence is not strong enough to warrant recommending that glucosamine sulphate should be prescribed on the NHS. However, they agree there is some evidence of benefit and suggest that people who buy the supplement over the counter should take 1,500mg for three months daily, then assess its effectiveness.
  • Hyaluronic acid injections (such as Synvisc, Duralane). The NICE team concluded that they are not sufficiently cost-effective to be prescribed on the NHS.
  • Arthroscopic lavage and debridement (also known as a knee washout). No better than placebo, and only to be used if the knee has “locked.”

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