Osteoarthritis NICE Clinical Guideline 177 – Feb 2014 Replacing guideline 59 – Feb 2008

1. OsteoarthritisNICE Clinical Guideline 177 – Feb 2014Replacing guideline 59 – Feb 2008 By Dan Alston

3. Definition • 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”.

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

5. Diagnosis • 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.

6. History should include - 1. • 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.

7. History should include – 2 • 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

8. History should include - 3 • 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.

9. History should include - 4 • Pain assessment 1) Self-help strategies. 2) Analgesics (Drugs, doses, frequency, timing, side effects).

10. Atypical features • 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.

11. Management • 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

12. DO NOT OFFER • Glucosamine or chondroitin products. • Acupuncture. • Rubefacients

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

14. Exercise • 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.

15. Footwear and aids • 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.

16. Analgesics • 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.

17. NSAID/COX-2 inhibitors. • Avoid etoricoxibfirst line • Co-prescribe with cheapest (Lowest acquistion costs) PPI • If on low dose aspirin consider alternative analgesia first.

18. Follow-up and reviews. • 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.

19. Referral for Surgery • 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.”

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

21. NICE • NICE acknowledge very little research into OA. • Most research into treatments for single joint without any co-morbidities. • Not much research in elderly.

22. Summary • 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.