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Osteoarthritis (OA) is the most common form of arthritis in the UK and also the most common cause of disability. It can affect any joint but is mainly found in the knee, hip, spine, hand, and, less commonly, the feet.1 At least 5 million people in the UK have X-ray evidence of OA of the hands, knees, or hips.1 It is a common cause of disability worldwide, affecting 9.6% of men and 18% of women aged >60 years. Increased life expectancy and ageing populations with increasing obesity levels are expected to make OA the fourth leading cause of disability globally by the year 2020.2 The total cost burden of OA on the UK economy is estimated at 1% of the annual gross national product; in 1999–2000, 36 million working days were lost because of OA, costing the economy nearly £3.2 billion in lost production.1

Need for the guideline

Osteoarthritis causes pain, reduced function of affected joints, and reduced mobility. It can affect every aspect of a person’s daily life and their overall quality of life. The numerous forms of potential treatments and the uncertainty surrounding them make publication of the NICE guideline, Osteoarthritis: the care and management of osteoarthritis in adults,3 very welcome.

How will the guideline improve care?

The patient support group Arthritis Care has hailed the NICE guideline as ‘robust, far-sighted, and innovative, a genuine first. Until now, people with OA have had a Cinderella service, and have often felt sidelined by the system.’4Patient-centred care is at the heart of the guideline.3,5 Treatment and care should take into account patients’ needs and preferences, and people with OA should have the opportunity to make informed decisions, in partnership with their healthcare professionals. Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written information tailored to the individual patient’s needs. Treatment and care, and the information patients are given about it, should be culturally appropriate. It should also be accessible to people with additional needs, such as those with physical, sensory, or learning disabilities, and to people who do not speak or read English.3

What is osteoarthritis?

In a change to accepted beliefs of many patients and professionals, the guideline challenges the view that the symptoms of OA inevitably deteriorate over time. Osteoarthritis is a metabolically active ‘repair process’ that takes place in all joint tissues and involves localised loss of cartilage and remodelling of adjacent bone.5 A variety of joint traumas may trigger the need to repair. Osteoarthritis often makes up for the initial trauma with a slow but efficient repair process that results in a structurally different but symptom-free joint. Overwhelming trauma or compromised repair potential in some patients results in a failure of the process to compensate, which results in continuing tissue damage and symptomatic OA or ‘joint failure’. There is therefore extreme variability in clinical presentation and outcome between patients and also at different joints in the same person.

In a prospective observational study of a population of 27,000 people in primary care, 587 of those identified by questionnaire (out of 2437 returned forms) as having moderate or severe hip or knee pain were followed up at 7 years. Overall, pain and disability had worsened, but 35% and 29% of those initially reporting hip and knee pain, respectively, had noticed an improvement. Those who did improve tended to have a lower BMI and less self-reported co-morbidity.6

Core treatments

The other new recommendation in the guideline is that all patients should receive the following three core treatments:3

• education, advice, and appropriate information
• advice about exercise: both local muscle strengthening exercise and general aerobic fitness, irrespective of age, co-morbidity, pain severity, or disability
• advice to lose weight if overweight, in line with the NICE guideline on obesity.7

Holistic approach

The NICE guideline advocates a holistic approach to the assessment and management of OA. Healthcare professionals should assess the effect of OA on the individual’s:3

• function
• quality of life
• occupation
• mood, particularly depression
• relationships
• leisure activities.

The guideline recommends that:3

• people with symptomatic OA should be reviewed periodically, taking into account their individual needs
• the management plan should be devised in partnership with the patient, and should take into consideration any co-morbidities that might increase the effect of OA
• accurate verbal and written information should be given to all people with OA to improve their understanding of the condition, its management, and to counter the erroneous view that it is inevitably progressive and untreatable
• the patient and their healthcare professional should share information regularly rather than simply at the time of presentation.
• self-management strategies designed for the individual patient should be agreed with the healthcare professional, to include positive behavioural changes incorporating core advice to exercise and try and lose weight if obese.

Treatment

Figure 1 gives an overview of the treatments that can be used for OA and further details of these are given in Table 1. The diagram above presents the order in which treatments are considered, working from the centre outwards. Individual needs, risk factors, and preferences will govern the treatment approach adopted.3 The order of treatments is as follows: the inner ring starts with the three core treatments that should be considered for every person with OA; the middle ring shows options for further treatment if necessary, and contains relatively safe pharmaceutical options; the outer circle shows adjunctive treatments that can be considered but which offer less well-proven efficacy, less symptom relief, or increased risk to the patient.

Several treatments were not recommended by the guideline, either because of insufficient evidence of efficacy (chondroitin, rubefacients), or because of adverse cost–benefit analysis (glucosamine hydrochloride, intra-articular hyaluronans, electro-acupuncture). There was evidence of short-term benefit from glucosamine sulphate 1500 mg daily, but as it was unlicensed and the trials showed considerable heterogeneity it was felt that it could not be recommended for prescribing at cost to the NHS. Practitioners can still recommend a short-term trial as an over the counter product. Similarly, despite some evidence indicating that acupuncture may help some patients, the evidence was not strong enough to support it being funded by the NHS. The guideline development group said further research was needed to identify the subgroup of patients that might benefit from use of intra-articular hyaluronans. Joint lavage and debridement was only recommended if the mechanical symptom of locking (not to be confused with gelling) was present.

Figure 1: Model for treatment options*

*Treatment options begin in the central core with simple, safe options and then progress outwards to preferred pharmacological options. The outer ring shows alternatives with higher cost or lower efficacy or increased risk to the patient, which could be used as adjunctive treatments to the inner options.
NSAIDs=non-steroidal anti-inflammatory drugs; COX-2=cyclo-oxgenase-2; TENS=transcutaneous electrical nerve stimulation
Adapted from National Institute for Health and Clinical Excellence (NICE) (2008) CG 59 Osteoarthritis: the care and management of osteoarthritis in adults. London: NICE. Reproduced with permission.
Available from www.nice.org.uk.

Table1: Treatment options for OA after implementation of core advice
Treatment	Comments
First line
Topical NSAIDs	For superficial joints like knees and hands
Paracetamol	Regular dosing may be required
Second line
Supports and braces	If biomechanical joint pain or instability
Intra-articular corticosteroid injections	As an adjunct treatment for moderate to severe pain (this could either be done at the GP practice, intermediate clinics, or consideration might be given to asking the PCT to fund this through a locally enhanced service)
Opioids	Risks and benefits should be considered, particularly in elderly people
Joint arthroplasty	If a patient with OA is experiencing joint symptoms (pain, stiffness and reduced function) that are impacting significantly on his or her quality of life, and which are not improved by non-surgical treatment, referral for joint replacement surgery should be considered The patient should be referred in time before the onset of prolonged, established functional limitation and severe pain
Oral NSAIDs including COX-2 inhibitors	Based on up-to-date evidence on efficacy and adverse events, current costs, and an expanded health-economic analysis of cost effectiveness, there is recognition of an increased role for COX-2 inhibitors, and an increased awareness of all potential adverse events (gastrointestinal, liver, and cardiorenal) COX-2 inhibitors should be coprescribed with a PPI Coprescription with a PPI reduces the risk of GI bleeding, but there is increasing concern about long-term use of PPIs and their impact on future fractures (this concern was built into the health economic model). Oral NSAIDs/COX-2 inhibitors should be used at the lowest effective dose for the shortest possible period of time Oral NSAIDs/COX-2 inhibitors have similar analgesic effect but vary in their potential GI, liver, and cardiorenal toxicity. Healthcare professionals should take into account individual patient risk factors, including age when choosing the agent and dose. Appropriate assessment must be carried out and/or ongoing monitoring of the risk factors implemented when prescribing these drugs
TENS	The best evidence is for pain and stiffness of the knee. Proper training for patients could improve the efficacy of this treatment
Local heat and cold	This is a safe and low cost measure, which can be part of self-management
Capsaicin	Evidence is for use on knees, but it can be used for hand joint OA
Manual therapy (manipulation and stretching)	Particularly suitable for patients with early symptoms of OA of the hip
Assistive devices	Examples are: walking sticks, tap turners
Shock-absorbing shoes or insoles	Trainers are useful, as are walking shoes. Sorbothane insoles from a sports shop can be of benefit. Several makes of shoe now feature shock-absorbing soles
OA=osteoarthritis; NSAIDs=non-steroidal anti-inflammatory drugs; COX-2=cyclooxygenase-2; PPI=proton pump inhibitor; GI=gastrointestinal

Promoting best practice

The NICE guideline on osteoarthritis will promote best practice in primary care by:

• promoting a patient-centred approach by health professionals
• treating the patient, not the disease process
• recognising depression, which can act as a barrier to self-help
• creating opportunities for health advice on OA to be delivered by nurses, physiotherapists, and other allied health professionals
• promoting patient self help, in the knowledge that symptoms of osteoarthritis do not necessarily get worse
• advocating exercise for all—either at individual level or as an exercise strategy for the whole local population (there is an opportunity for GPs to try and influence local health commissioners in provision of suitable exercises, such as aquaerobics, chair-based exercise, and safe areas for cycling)
• altering attitudes to OA—particularly ‘nothing can be done’, by providing a toolbox of evidence-based interventions
• minimising unnecessary iatrogenic problems caused by non-steroidal anti-inflammatory drugs (NSAIDs) or opioids
• identifying people suitable for surgery before they become disabled by OA.

Summary

The guideline from NICE on Osteoarthritis: the care and management of osteoarthritis in adults is welcome for its pragmatic and patient-centred approach to the treatment of OA. A future update of the guideline could consider including a tool to help GPs calculate the approximate risk to patients of individual NSAIDs/COX-2 inhibitors, and more discussion of surgical options or the place of the newer joint resurfacing techniques.

The guideline encourages self-help, giving several effective treatments for this, and provides healthcare professionals with a toolbox of therapeutic options. It increases patient safety by encouraging full consent, with knowledge of risk and benefit, when discussing oral NSAID therapy, opioids and surgical options. The guideline removes discriminatory barriers to referral for surgery, such as age, co-morbidity, and weight.

Key points

Advise patients on the three core treatments: advice and information, including advice about appropriate shock-absorbing footwear local muscle strengthening and aerobic exercise weight loss if overweight Adopt a holistic approach to assessment and management of patients with OA, looking at the impact on their quality of life, mood, relationships, and leisure activities Share information, tailored to the individual patient, and encourage him/her/the carer to participate in establishing a management plan Inform misconceptions on OA: symptoms will not always become worse Use the treatment model in the guideline when implementing therapies Health advice for patients with OA can be delivered by practice nurses and other healthcare professionals Consider referral for joint replacement surgery if joint symptoms have a substantial impact on quality of life and are refractory to non-surgical treatments

OA=osteoarthritis

Practice-based commissioning take home messages

written by Dr David Jenner, NHS Alliance PBC Lead Core advice about lifestyle exercise and weight reduction is core to treatment (and can be easily delivered in primary care) Paracetamol and topical NSAIDs (for superficial joints) are first-line pharmacological treatments COX-2 inhibitors and NSAIDs should be used at lowest dose for the shortest possible period of time Physiotherapy is especially valuable for early OA of the hip Joint lavage should only be performed where there is a history of locking of the joint A simple care pathway for OA referrals could easily be modelled locally based on this guidance Cost of topical NSAID: piroxicam gel 0.5% 60 g = £2.71; 112 g = £2.20a Rheumatology outpatient appointment = £258 (new), £105 (follow up)

PBC=practice-based commissioning; NSAIDs=non-steroidal anti-inflammatory drugs; COX-2=cyclooxygenase-2; OA=osteoarthritis awww.ppa.org.uk bwww.dh.gov.uk/paymentbyresults/

NICE implementation tools

NICE has developed the following tools to support implementation of its guideline on the care and management of osteoarthritis in adults. They are now available to download from the NICE website: www.nice.org.uk. Costing tools National cost reports and local cost templates for the guideline have also been produced: Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline. Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets. Slide set The slides are aimed at supporting organisations to raise awareness of the guideline at a local level and can be edited to cater for local audiences. They do not cover all the recommendations from the guideline but contain key messages, and should be used in conjunction with the Quick Reference Guide. Audit support Audit support has been developed to assess current practice in the management of osteoarthritis compared with the guideline recommendations. Audit criteria based on key priorities for implementation in the guideline are provided, which can be adapted for use locally. Although the given standard should be aimed for, a more realistic local short-term standard can be set based on discussion with clinicians.

Click here for CPD questions on this article and the NICE guideline on the care and management of osteoarthritis in adults

References

1. Arthritis and Musculoskeletal Alliance. Standards of care for people with osteoarthritis. London: ARMA, 2004. www.arma.uk.net
2. Woolf A, Plfeger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003; 81 (9): 646–656.
3. National Institute for Health and Clinical Excellence. Osteoarthritis: the care and management of osteoarthritis in adults. Clinical Guideline 59. London: NICE, 2008.
4. Arthritis Care. Statement and press releases. Arthritis care [Online] 27 Feb 2008. www.arthritiscare.org.uk/NewsRoom/Latestnewsstories/NICElaunchesnewOAguidelines
5. National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults. London: Royal College of Physicians, 2008.
6. Peters T, Sanders C, Dieppe P, Donovan J. Factors associated with change in pain and disability over time: a community-based prospective observational study of hip and knee osteoarthritis. Br J Gen Pract 2005; 55 (512): 205–211.
7. National Institute for Health and Clinical Excellence. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children.London: NICE, 2006.G

Dr Michael Burke
GP Principal, Wirral
GPwSI in Musculoskeletal Medicine
Member of the NICE Guideline Development Group
Steering committee member for Primary Care Rheumatology Society