Care and Management of Osteoarthritis in Adults (NICE Guideline)

Summary of NICE advice on OA assessment and treatment.

The care and management of osteoarthritis in adults

Holistic assessment

Assess effect of osteoarthritis (OA) on patient's:

  • Function
  • Quality of life
  • Occupation
  • Mood
  • Relationships
  • Leisure activities
Management
In partnership with the patient, formulate and regularly review a management plan that includes core symptom-relieving treatment, adjunctive treatment and self-management.

Core symptom-relieving treatment

Offer verbal and written advice on:

  • OA and its management, to enhance understanding
  • Need for exercise to strengthen local muscle and improve aerobic fitness (irrespective of age, comorbidities and severity of OA)
  • Interventions to aid weight loss (if overweight)
  • Appropriate footwear in lower limb OA

Adjunctive treatment

Consider the following pharmacological options:

  • Paracetamol (given regularly if needed)
  • Topical NSAIDs for knee or hand OA
  • Topical capsaicin for knee or hand OA
  • Intra-articular corticosteroid injections for moderate to severe pain

If paracetamol and/or topical NSAIDs are ineffective, consider:

  • Adding opioid
  • Prescribing oral NSAID or COX-2 inhibitor in addition to paracetamol or instead of topical NSAID:
    • Co-prescribe with a proton pump inhibitor
    • Use lowest effective dose for shortest possible duration
    • Choose agent and dose on basis of risk factors for GI, liver and cardiorenal toxicity; monitor for any such effects
    • If patient is already taking low-dose aspirin for another condition, consider an alternative analgesic
    • Do not prescribe etoricoxib 60mg as first-line treatment

Consider the following non-pharmacological options:

  • Heat and cold packs
  • Transcutaneous electrical nerve stimulation (TENS)
  • Manipulation and stretching (particularly for hip OA)
  • Assessment for bracing, joint supports or insoles (for biomechanical joint pain or instability)
  • Assistive devices (eg, walking sticks, tap turners) to address specific problems. Seek expert advice if needed.

Self-management

  • Exercise
  • Weight loss (if overweight)
  • Suitable footwear
  • Heat and cold packs
  • TENS
Referral for surgery
  • Consider referral to joint surgery if symptoms continue to substantially affect quality of life despite medical treatment. Refer before there is prolonged and established functional limitation and severe pain.
  • Consider referral for arthroscopic lavage and debridement only in patients with knee OA and clear history of mechnical locking in the knee.
  • Do not use scoring tools for prioritisation or refuse referral on grounds of age, gender, smoking, obesity, etc.
Treatments not recommended
  • Rubefacients
  • Intra-articular hyaluronan injections
  • Acupuncture
  • Chondroitin or glucosamine

Adapted from: NICE Clinical Guideline 177 (February 2014) - The care and management of osteoarthritis in adults.