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.
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.
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. (more ...)
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]