Osteoarthritis NICE Clinical Guideline 177 – Feb 2014

Replacing guideline 59 – Feb 2008

By Dan Alston

Osteoarthritis “refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life.”

“Pain in itself is also a complex biopsychosocial issue”.

“Poor link between x-rays and symptoms”. “Not caused by ageing and does not

necessarily deteriorate”.

Definition

“Localised loss of cartilage, remodelling of adjacent bone and associated inflammation”.

Pathology

Diagnose OA clinically if: Is 45 or over and Has activity related joint pain. Has either no morning joint related stiffness

or morning stiffness that lasts no longer than 30mins.

Diagnosis

Social 1) Effects on Life ( ADL’s, Family duties, Hobbies) 2) Lifestyle expectations. Health Beliefs (I.C.E. , Current knowledge

OA) Occupational

1) Ability to perform job short and long term. 2) Adjustments to home or workplace.

History should include - 1.

Mood 1) Screen for depression. 2) Other stressors in life. Quality of sleep Support network

1) ICE main carer 2) How carer is coping 3) Isolation

History should include – 2

Other MSK pain – Including evidence chronic pain.

Attitudes to exercise. Influence of co-morbidity

1) Interaction of two or more co-morbidities 2) Falls 3) Assessment of most appropriate medications 4) understanding of surgical options. 5) Fitness for surgery.

History should include - 3

Pain assessment 1) Self-help strategies. 2) Analgesics (Drugs, doses, frequency, timing, side effects).

History should include - 4

History of trauma, prolonged morning joint related stiffness, rapid worsening of symptoms. Presence of a hot swollen joint. Bone pain

Differentials – Gout, inflammatory arthritis, septic arthritis, malignancy.

Atypical features

To all patients offer advice: 1) Verbal and written info about OA. 2) On activity and exercise. 3) Weight loss if overweight/obese. 4) Correct footwear and aids. 5) Pacing 6) Thermotherapy (Local cold or heat) 7) Pharmalogical 8) Surgical 9) Electrotherapy - TENS

Management

Glucosamine or chondroitin products. Acupuncture. Rubefacients

DO NOT OFFER

“Information sharing is an ongoing, integral part of the management plan rather than a single event at time of presentation.”

Information sharing

Irrespective of age, comorbidity, pain severity or disability.

Considered a core treatment of OA. 1) Local Muscle strengthening

and 2) General aerobic fitness. Notes – Not specified if done via NHS or

privately. Manipulation and stretching particularly for

OA hip.

Exercise

Shock absorbing footwear for lower limb OA.

Consider assessment for bracing/joint supports/insoles if biomechanical joint pain or instability.

Seek expert advice such as occupational therapists or disability equipment assessment centres for aids such as walking sticks.

Footwear and aids

Awaiting review by MHRA (Medicines and healthcare Products regulatory Agency).

So guidance will be updated but is largely unchanged from 2008.

Except Paracetamol now felt to be less effective.

1st line still – Paracetamol and Topical NSAID 2nd line – Add opiate/Oral NSAID/COX-2 inhibitor. Consider Topical capsaicin for hand and knee

OA. Consider intra-articuar corticosteroids.

Analgesics

Avoid etoricoxib first line Co-prescribe with cheapest (Lowest

acquistion costs) PPI If on low dose aspirin consider alternative

analgesia first.

NSAID/COX-2 inhibitors.

Regular reviews – agree timing with patient. Consider annual reviews if troublesome joint pain,

more than one joint with symptoms. More than one co-morbidity, taking regular medications for there OA.

Monitor impact on everyday activities and quality of life.

Monitor long term course of condition. Discuss patients knowledge, address any concerns. Review treatment. Support self management.

Follow-up and reviews.

Base decision to refer on discussion with patients (patient representatives), referring clinicians and surgeons. Rather than using scoring tools.

Make sure has been offered non surgical options first.

Consider referral for joint surgery if symptoms have a substantial impact on there quality of life.

“Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain.”

Referral for Surgery

Do not refer for arthroscopic knee surgery unless clear history of mechanical locking.

Surgery

NICE acknowledge very little research into OA.

Most research into treatments for single joint without any co-morbidities.

Not much research in elderly.

NICE

Diagnosis clinical not x-ray. Extensive history taking including

biopsychosocial. Exercise very important. Information sharing important. 1st line non-pharmalogical. 2nd line pharmalogical. 3rd line Surgery.

Summary