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Key priorities for implementation
Implementation tools
NICE has developed tools to help organisations ● Audit support for monitoring local practice.
● Exercise1 should be a core treatment (see recommendation 1.1.5) for people with osteoarthritis, irrespective of age, comorbidity, pain severity or disability. Exercise should include: – costing report to estimate the national savings ● Slides highlighting key messages for – costing template to estimate the local costs ● Referral for arthroscopic lavage and debridement2 should not be offered as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanicallocking (not gelling, ‘giving way’ or X-ray evidence of loose bodies).
● Healthcare professionals should consider offering paracetamol for pain relief in addition to Further information
core treatment (see figure 2); regular dosing may be required. Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, Ordering information
For printed copies of the quick reference guide or cyclo-oxygenase 2 (COX-2) inhibitors or opioids.
You can download the following documents from ‘Understanding NICE guidance’, phone NICE ● Healthcare professionals should consider offering topical NSAIDs for pain relief in addition to core treatment (see figure 2) for people with knee or hand osteoarthritis. Topical NSAIDs and/or ● A quick reference guide (this document) – a paracetamol should be considered ahead of oral NSAIDs, COX-2 inhibitors or opioids.
Quick reference guide
● When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a ● N1XXX (‘Understanding NICE guidance’).
standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg). In either case, these should ● The NICE guideline – all the recommendations. be co-prescribed with a proton pump inhibitor (PPI), choosing the one with the lowest Related NICE guidance
● ‘Understanding NICE guidance’ – information For information about NICE guidance that has been issued or is in development, see the website ● Referral for joint replacement surgery should be considered for people with osteoarthritis who ● The full guideline – all the recommendations, experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact Osteoarthritis
on their quality of life and are refractory to non-surgical treatment. Referral should be made reviews of the evidence they were based on.
before there is prolonged and established functional limitation and severe pain.
NICE has issued clinical guidelines on obesity(CG43) and depression (CG23); technology The care and management of osteoarthritis in adults appraisal guidance on ‘Guidance on the use of 1 It has not been specified whether exercise should be provided by the NHS or whether the healthcare professional should cyclo-oxygenase (COX) II selective inhibitors, provide advice and encouragement to the patient to obtain and carry out the intervention themselves. Exercise has been foundto be beneficial but the clinician needs to make a judgement in each case on how to effectively ensure patient participation.
celecoxib, rofecoxib, meloxicam and etodolac This will depend upon the patient's individual needs, circumstances, self-motivation and the availability of local facilities.
for osteoarthritis and rheumatoid arthritis’ (TA27); 2 This recommendation is a refinement of the indication in ‘Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis’ (NICE interventional procedure guidance 230). This guideline has reviewed the clinical and cost-effectiveness evidence, which has led to this more specific recommendation on the indication for which arthroscopic lavage and debridement is judged to be clinically and cost effective.
of osteoarthritis’ (IPG230), ‘Single mini- About this booklet
This is a quick reference guide that summarises the recommendations NICE has made to the NHS in Osteoarthritis: the care and management of osteoarthritis in adults (NICE clinical guideline XXX). National Institute for
invasive two-incision surgery for total hip Health and Clinical Excellence
replacement’ (IPG112), and ‘Artificial This guidance is written in the following context
NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales. This guidance represents the view of the Institute, which was arrived at after careful consideration Updating the guideline
of the evidence available. Healthcare professionals are expected to take it fully into account This guideline will be updated as needed, when exercising their clinical judgement. The guidance does not, however, override the individual and information about the progress of any responsibility of healthcare professionals to make decisions appropriate to the circumstances of update will be posted on the NICE website the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.
Developed by the National Collaborating Centre for Chronic Conditions Assessment, management and treatment of osteoarthritis in adults
Holistic assessment
Assess the effect of osteoarthritis on the person’s function, quality of life, occupation, mood, relationships and leisure activities. Use the following as an aid to assessment1.
The patient’s existing
The patient’s support
The patient’s mood
The effect of osteoarthritis on:
Pain assessment
Other musculoskeletal pain
Comorbidities
thoughts
Assessment
Assessment
The patient’s attitude to
exercise
● their occupation, including short- and long-term ability to perform their job (are any adjustments Core symptom-relieving therapies
Management plan
eatments
Offer all people with clinically symptomatic osteoarthritis advice on the following core treatments.
● Formulate and agree a management plan (including individualised self-management strategies) Patient self-management strategies*
eatments
in partnership with the person with osteoarthritis. This should: Access to appropriate information
Activity and exercise
Interventions to
– target positive behavioural changes, such as exercise, weight loss, use of suitable footwear ● Weight loss if the person is overweight or obese.
help weight loss2
– emphasise the core treatments
● Application of heat or cold packs to the site of pain.
– take into account comorbidities that compound the effect of osteoarthritis symptoms.
● Transcutaneous electrical nerve stimulation (TENS) for pain relief.
● Explain clearly to the patient treatment options that are available to them and any risks and * Please refer to each individual recommendation within the pathway of ● Offer information about osteoarthritis to the patient regularly.
for people with lower limb osteoarthritis.
Management and cor
Management and cor
Box 1 Treatment with oral NSAIDs/COX-2 inhibitors3
● Offer a standard NSAID or a COX-2 inhibitor (but not etoricoxib 60 mg) as a first choice. Co-prescribe with a proton pump inhibitor (choose the agent with the lowest acquisition cost).
Treatments not recommended
● Prescribe at the lowest effective dose for the shortest possible period of time.
● Owing to potential gastrointestinal, liver and cardio-renal toxicity: When a person presents with osteoarthritis, – take into account individual patient risk factors, including age, when choosing the NSAID/COX-2 do not prescribe:
– assess and/or monitor patient risk factors ● intra-articular hyaluronan injections Adjuncts to core therapies
– consider prescribing an alternative analgesic if the patient is already taking low-dose aspirin for another Consider offering the following as adjuncts to core treatment.
● chondroitin or glucosamine products.
Pharmacological
● Paracetamol (regular dosing may be required).
● Topical non-steroidal anti-inflammatory drugs (NSAIDs) for people with knee or hand osteoarthritis.
Referral for surgery
Patient-centred care
● Offer paracetamol and/or topical NSAIDs before considering oral NSAIDs, cyclo-oxygenase 2 (COX-2) Consider a person with osteoarthritis for referral for joint surgery if they: ● have already been offered all of the core treatments, and Treatment and care should take into account patients’ individual needs and preferences. Good If paracetamol or topical NSAIDs are insufficient at relieving pain, consider adding: ● are experiencing joint symptoms (such as pain, stiffness and reduced function) that have a substantial impact on eatments
– opioid analgesics (consider the risks and benefits of prescribing opioids, particularly in elderly people) communication is essential, supported by evidence-based information, to allow patients to reach eatments
their quality of life and are refractory to non-surgical treatment.
– an oral NSAID/COX-2 inhibitor (see box 1) to the paracetamol3.
informed decisions about their care. Follow Department of Health advice on seeking consent if ● If paracetamol or topical NSAIDs are ineffective at relieving pain, then consider substitution with an oral If a clear history of mechanical locking in the knee is present, offer referral for arthroscopic lavage and debridement.
needed. If the patient agrees, families and carers should have the opportunity to be involved in Do not offer this procedure for the treatment of any other symptom of osteoarthritis.
● Topical capsaicin for knee or hand osteoarthritis.
● Intra-articular corticosteroid injections when pain is moderate to severe.
Adjunctive tr
Adjunctive tr
● discussions should involve the referring healthcare professional, patient representatives and the surgeon Non-pharmacological
Application of heat or cold to the site of pain.
This is a summary of key topics that should be addressed when assessing a person with osteoarthritis. Within each topic – use current scoring tools for prioritisation ● Transcutaneous electrical nerve stimulation (TENS)4.
are a few suggested specific points. This list is not exhaustive, and not every topic listed will be relevant for all people with – allow patient-specific factors (including age, gender, smoking, obesity and comorbidities) to be barriers for referral.
● Manipulation and stretching, particularly for hip osteoarthritis.
● Assessment for bracing/joint supports/insoles for people with biomechanical joint pain or instability.
2 See ‘Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in ● Assistive devices (for example, walking sticks and tap turners) for people with specific problems with adults and children’ (NICE clinical guideline 43).
daily activities. Expert advice may be required from occupational therapists or disability equipment 3 These recommendations replace the osteoarthritis aspects only of 'Guidance on the use of cyclo-oxygenase (Cox) II selective inhibitors, celecoxib, rofecoxib, meloxicam and etodolac for osteoarthritis and rheumatoid arthritis' (NICEtechnology appraisal 27).
4 If treatment is effective, advise people where they can purchase their own TENS machine.
National Institute for Health and Clinical Excellence, 2008. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the Institute.

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