Transcript Osteoarthritis NICE Clinical Guideline 177 * Feb 2014

By Dan Alston
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Osteoarthritis “refers to a clinical syndrome of
joint pain accompanied by varying degrees of
functional limitation and reduced quality of
life.”
“Pain in itself is also a complex
biopsychosocial issue”.
“Poor link between x-rays and symptoms”.
“Not caused by ageing and does not
necessarily deteriorate”.
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“Localised loss of cartilage, remodelling of
adjacent bone and associated inflammation”.
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Diagnose OA clinically if:
Is 45 or over and
Has activity related joint pain.
Has either no morning joint related stiffness
or morning stiffness that lasts no longer than
30mins.
Social
1) Effects on Life ( ADL’s, Family duties,
Hobbies)
2) Lifestyle expectations.
 Health Beliefs (I.C.E. , Current knowledge OA)
 Occupational
1) Ability to perform job short and long
term.
2) Adjustments to home or workplace.
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Mood
1) Screen for depression.
2) Other stressors in life.
Quality of sleep
Support network
1) ICE main carer
2) How carer is coping
3) Isolation
Other MSK pain – Including evidence chronic
pain.
 Attitudes to exercise.
 Influence of co-morbidity
1) Interaction of two or more co-morbidities
2) Falls
3) Assessment of most appropriate
medications
4) understanding of surgical options.
5) Fitness for surgery.
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Pain assessment
1) Self-help strategies.
2) Analgesics (Drugs, doses, frequency,
timing, side effects).
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History of trauma, prolonged morning joint
related stiffness, rapid worsening of
symptoms. Presence of a hot swollen joint.
Bone pain
Differentials – Gout, inflammatory arthritis,
septic arthritis, malignancy.
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To all patients offer advice:
1) Verbal and written info about OA.
2) On activity and exercise.
3) Weight loss if overweight/obese.
4) Correct footwear and aids.
5) Pacing
6) Thermotherapy (Local cold or heat)
7) Pharmalogical
8) Surgical
9) Electrotherapy - TENS
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Glucosamine or chondroitin products.
Acupuncture.
Rubefacients
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“Information sharing is an ongoing, integral
part of the management plan rather than a
single event at time of presentation.”
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Irrespective of age, comorbidity, pain severity
or disability.
Considered a core treatment of OA.
1) Local Muscle strengthening
and
2) General aerobic fitness.
Notes – Not specified if done via NHS or
privately.
Manipulation and stretching particularly for
OA hip.
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Shock absorbing footwear for lower limb OA.
Consider assessment for bracing/joint
supports/insoles if biomechanical joint pain
or instability.
Seek expert advice such as occupational
therapists or disability equipment assessment
centres for aids such as walking sticks.
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Awaiting review by MHRA (Medicines and
healthcare Products regulatory Agency).
So guidance will be updated but is largely
unchanged from 2008.
Except Paracetamol now felt to be less effective.
1st line still – Paracetamol and Topical NSAID
2nd line – Add opiate/Oral NSAID/COX-2
inhibitor.
Consider Topical capsaicin for hand and knee
OA.
Consider intra-articuar corticosteroids.
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Avoid etoricoxib first line
Co-prescribe with cheapest (Lowest
acquistion costs) PPI
If on low dose aspirin consider alternative
analgesia first.
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Regular reviews – agree timing with patient.
Consider annual reviews if troublesome joint
pain, more than one joint with symptoms. More
than one co-morbidity, taking regular
medications for there OA.
Monitor impact on everyday activities and quality
of life.
Monitor long term course of condition.
Discuss patients knowledge, address any
concerns.
Review treatment.
Support self management.
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Base decision to refer on discussion with patients
(patient representatives), referring clinicians and
surgeons. Rather than using scoring tools.
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Make sure has been offered non surgical options
first.
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Consider referral for joint surgery if symptoms
have a substantial impact on there quality of life.
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“Refer for consideration of joint surgery before
there is prolonged and established functional
limitation and severe pain.”
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Do not refer for arthroscopic knee surgery
unless clear history of mechanical locking.
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NICE acknowledge very little research into
OA.
Most research into treatments for single joint
without any co-morbidities.
Not much research in elderly.
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Diagnosis clinical not x-ray.
Extensive history taking including
biopsychosocial.
Exercise very important.
Information sharing important.
1st line non-pharmalogical.
2nd line pharmalogical.
3rd line Surgery.