The care and management of osteoarthritis in adults

National Institute for Health and Care Excellence

Key priorities for implementation

• Exercise* should be a core treatment for people with osteoarthritis, irrespective of age, co-morbidity, 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; regular dosing may be required. Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclo-oxygenase 2 (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

Holistic assessment

• Use the following as an aid to assessment:*
  • the patient’s existing thoughts
    • what concerns do they have?
    • what are their expectations?
    • what do they know about osteoarthritis?
  • the patient’s support network
    • is the patient isolated or do they have a carer?
    • how is the main support giver coping? What are their ideas, concerns and expectations?
  • the patient’s mood
    • screen for depression
    • are there any other stresses in their life?
  • the patient’s attitude to exercise
  • the effect of osteoarthritis on:
    • activities of daily living
    • family duties
    • hobbies
    • lifestyle expectations
    • quality of sleep
    • their occupation, including short- and long-term ability to perform their job (are any adjustments to home or workplace required?)
  • pain assessment:
• • • assess self-help strategies the patient is using
    • assess current drugs being used, including their doses, frequency, timing and any possible side effects
  • other musculoskeletal pain
  • • is there evidence of a chronic pain syndrome?
    • are there other treatable sources of pain (for example, periarticular pain, trigger finger, ganglion or bursitis)?
  • comorbidities
    • if two or more morbidities, consider any interaction
    • is the patient fit for surgery?
    • assess the most appropriate drug therapy
    • is the patient prone to falls?

Core symptom-relieving therapies

• Access to appropriate information
  • offer accurate verbal and written information to enhance understanding of osteoarthritis and management of the condition
  • offer advice on appropriate footwear (including shock-absorbing properties) for people with lower limb osteoarthritis
• Activity and exercise
  • exercise should include local muscle strengthening and general aerobic fitness
  • exercise should be a core treatment irrespective of age, pain severity, comorbidity and disability
• Interventions to help weight loss§
  • offer to people with osteoarthritis who are overweight or obese

Adjuncts to core therapies

• Pharmacological:
  • paracetamol (regular dosing may be required)
  • topical NSAIDs for people with knee or hand osteoarthritis
  • offer paracetamol and/or topical NSAIDs before considering oral NSAIDs, COX-2 inhibitors or opioids
  • if paracetamol or topical NSAIDs are insufficient at relieving pain, consider adding:
    • opioid analgesics (consider the risks and benefits of prescribing opioids, particularly in elderly people)
    • an oral NSAID/COX-2 inhibitor (see below) to the paracetamol|
• if paracetamol or topical NSAIDs are ineffective at relieving pain, then consider substitution with an oral NSAID/COX-2 inhibitor (see below)|
  • topical capsaicin for knee or hand osteoarthritis
  • intra-articular corticosteroid injections when pain is moderate to severe
• Non-pharmacological:
  • application of heat or cold to the site of pain
  • transcutaneous electrical nerve stimulation (TENS)¶
  • manipulation and stretching, particularly for hip osteoarthritis
  • assessment for bracing/joint supports/insoles for people with biomechanical joint pain or instability
  • assistive devices (for example, walking sticks and tap turners) for people with specific problems with daily activities. Expert advice may be required from occupational therapists or disability equipment assessment centres

Treatments not recommended

• When a person presents with osteoarthritis, do not prescribe:
  • rubefacients
  • intra-articular hyaluronan injections
  • electro-acupuncture**
  • chondroitin or glucosamine products

Treatment with oral NSAIDs/COX-2 inhibitors|

• Offer a standard NSAID or a COX-2 inhibitor (but not etoricoxib 60 mg) as a first choice. Co-prescribe with a PPI (choose the agent with the lowest acquisition cost)
• 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

Referral for surgery

• Consider a person with osteoarthritis for referral for joint surgery if they:
  • have already been offered all of the core treatments, and
  • are experiencing joint symptoms (such as pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment
• If a clear history of mechanical locking in the knee is present, offer referral for arthroscopic lavage and debridement. Do not offer this procedure for the treatment of any other symptom of osteoarthritis
• When making the decision to refer:
  • discussions should involve the referring healthcare professional, patient representatives and the surgeon
  • do not:
    • use current scoring tools for prioritisation
    • allow patient-specific factors (including age, gender, smoking, obesity and comorbidities) to be barriers for referral