NICE has published its guidance on management of osteoarthritis. ‘Osteoarthritis: the care and management of osteoarthritis in adults’ (NICE CG 59) offers best practice advice on the care of adults with osteoarthritis.
The guidance lists the following as key priorities for implementation
- Exercise should be a core treatment for people with osteoarthritis, irrespective of age, comorbidity, pain severity or disability. Exercise should include local muscle strengthening and general aerobic fitness.
- Referral for arthroscopic lavage and debridement should not be offered as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (not gelling, ‘giving way’ or X-ray evidence of loose bodies).
- Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatment (exercise, advice, etc); regular dosing may be required. Paracetamol and/or topical NSAIDs should be considered ahead of oral NSAIDs, COX-2 inhibitors or opioids.
- Healthcare professionals should consider offering topical NSAIDs for pain relief in addition to core treatment for people with knee or hand osteoarthritis. Topical NSAIDs and/or paracetamol 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 (other than etoricoxib 60 mg). In either case, these should be co-prescribed with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost.
- 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 are refractory to non-surgical treatment. Referral should be made before there is prolonged and established functional limitation and severe pain.
The following treatments are not recommended:
intra-articular hyaluronan injections
chondroitin or glucosamine products (but see our recent blog)
Health professionals should take these guidelines fully into account when caring for people with osteoarthritis. It is particularly important to use oral NSAIDs, including COX-2 inhibitors (coxibs), only when other, safer treatments are ineffective or not tolerated. When their use is essential, NICE recommends offering a standard NSAID or a COX-2 inhibitor (but not etoricoxib 60 mg) as a first choice. It recommends co-prescription with a proton pump inhibitor (choosing the agent with the lowest acquisition cost). In addition, NICE says
Prescribe at the lowest effective dose for the shortest possible period of time.
Owing to potential gastrointestinal, liver and cardio-renal toxicity:
take into account individual patient risk factors, including age, when choosing the NSAID/COX-2 inhibitor and dose to be prescribed
assess and/or monitor patient risk factors
consider prescribing an alternative analgesic if the patient is already taking low-dose aspirin for another condition.
As we have blogged previously, health professionals should bear in mind that many traditional NSAIDs, such as diclofenac, carry the same increased cardiovascular risks as COX-2 inhibitors (coxibs). Ibuprofen at 1200 mg/day or less, and naproxen 1000 mg/day do not carry these same cardiovascular risks and should be first choice agents for most patients (taking into account gastrointestinal risks and interpatient variability in response). Note also that, if an NSAID is essential for a patient already taking low-dose aspirin for another condition, health professionals should not avoid prescribing or recommending ibuprofen because of concerns about a possible interaction between the two drugs, to reduce the antiplatelet effects of aspirin. Although this has been observed in laboratory studies, there is no evidence that a clinically relevant interaction exists and European pharmacovigilance and regulatory agencies do not advise caution in this regard.
Readers should also remember that there is also little evidence that using a COX-2 inhibitor plus a PPI reduces the risk of GI damage more than using a standard NSAID plus a PPI – see the MeReC Extra on this for details:
“Benefits from gastroprotection largely depend on the individual patient’s baseline risk of GI complications. There is, as yet, no good evidence that adding a PPI to a coxib is more beneficial, equivalent or a worse option than adding a PPI to a traditional NSAID.”
You can find more information about osteoarthritis and its management, and the risks and benefits of NSAIDs and analgesics, on the Musculoskeletal Pain floor of NPC