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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
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.
Provide advice on the following to all people with symptomatic osteoarthritis:
Other treatments can be used as adjuncts to these core treatments (see figurefigure),), and a person with osteoarthritis may use several of these treatments. Some treatments will be useful only for certain joints.
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]
Consider risks and benefits of pharmacological treatments, particularly in elderly people and those with comorbidities.
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.
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.
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.
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.
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.