Osteoarthritis: care and management – NICE guideline

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This National Institute for Health and Care Excellence (NICE) guideline covers assessing and managing osteoarthritis in adults. It covers both pharmacological and non-pharmacological treatments. It promotes effective treatment options to control joint pain and improve function in people with osteoarthritis.

Key recommendations

Diagnosis

  • Diagnose osteoarthritis clinically without investigations if a person:
    • is 45 or over and
    • has activity-related joint pain and
    • has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes. [new 2014]

Holistic approach to osteoarthritis assessment and management

  • Offer advice on the following core treatments to all people with clinical osteoarthritis:
    • access to appropriate information
    • activity and exercise
    • interventions to achieve weight loss if the person is overweight or obese. [2008, amended 2014]

Education and self-management

  • Offer accurate verbal and written information to all people with osteoarthritis to enhance understanding of the condition and its management, and to counter misconceptions, such as that it inevitably progresses and cannot be treated. Ensure that information sharing is an ongoing, integral part of the management plan rather than a single event at time of presentation. [2008]
  • Agree individualised self-management strategies with the person with osteoarthritis. Ensure that positive behavioural changes, such as exercise, weight loss, use of suitable footwear and pacing, are appropriately targeted. [2008]

Non-pharmacological management

  • Advise people with osteoarthritis to exercise as a core treatment, irrespective of age, comorbidity, pain severity or disability. Exercise should include:
    • local muscle strengthening and
    • general aerobic fitness.

It has not been specified whether exercise should be provided by the NHS or whether the healthcare professional should provide advice and encouragement to the person to obtain and carry out the intervention themselves. Exercise has been found to be beneficial but the clinician needs to make a judgement in each case on how to effectively ensure participation. This will depend upon the person's individual needs, circumstances and self-motivation, and the availability of local facilities. [2008]

Referral for consideration of joint surgery

  • Base decisions on referral thresholds on discussions between patient representatives, referring clinicians and surgeons, rather than using scoring tools for prioritisation. [2008, amended 2014]
  • Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain. [2008, amended 2014]

Follow-up and review

  • Offer regular reviews to all people with symptomatic osteoarthritis. Agree the timing of the reviews with the person. Reviews should include:
    • monitoring the person's symptoms and the ongoing impact of the condition on their everyday activities and quality of life
    • monitoring the long-term course of the condition
    • discussing the person's knowledge of the condition, any concerns they have, their personal preferences and their ability to access services
    • reviewing the effectiveness and tolerability of all treatments
    • support for self-management. [new 2014]
  • Consider an annual review for any person with one or more of the following:
    • troublesome joint pain
    • more than one joint with symptoms
    • more than one comorbidity
    • taking regular medication for their osteoarthritis. [new 2014]

Contrary to popular belief, osteoarthritis is not caused by ageing and does not necessarily deteriorate. There are a number of management and treatment options (both pharmacological and non-pharmacological), which this guideline addresses and which represent effective interventions for controlling symptoms and improving function.

Guideline update 2014

This guideline update was originally intended to include recommendations based on a review of new evidence about the use of paracetamol, etoricoxib and fixed-dose combinations of NSAIDs (non-steroidal anti-inflammatory drugs) plus gastroprotective agents in the management of osteoarthritis. Draft recommendations based on the evidence reviews for these areas were presented in the consultation version of the guideline. Stakeholder feedback at consultation indicated that the draft recommendations, particularly in relation to paracetamol, would be of limited clinical application without a full review of evidence on the pharmacological management of osteoarthritis. NICE was also aware of an ongoing review by the MHRA (Medicines and Healthcare Products Regulatory Agency) of the safety of over-the-counter analgesics. Therefore NICE intends to commission a full review of evidence on the pharmacological management of osteoarthritis, which will start once the MHRA's review is completed, to inform a further guideline update.

Until that update is published, the original recommendations (from 2008) on the pharmacological management of osteoarthritis remain current advice. However, the Guideline Development Group (GDG) would like to draw attention to the findings of the evidence review on the effectiveness of paracetamol that was presented in the consultation version of the guideline. That review identified reduced effectiveness of paracetamol in the management of osteoarthritis compared with what was previously thought. The GDG believes that this information should be taken into account in routine prescribing practice until the planned full review of evidence on the pharmacological management of osteoarthritis is published (see the NICE website for further details).

The current update addresses issues around decision-making and referral thresholds for surgery, and includes new recommendations about diagnosis and follow-up. The update also contains recommendations based on new evidence about the use of nutraceuticals, hyaluronans and acupuncture in the management of osteoarthritis.

You can read the guideline on NICE's website.