NSAIDs analgesic of choice for osteoarthritis in draft NICE guidance

The draft guidance recommends that people with osteoarthritis requiring pharmacological management are offered a topical NSAID in the first instance while paracetamol is not recommended.

Three pairs of feet in trainers visible with people's hands reaching down to touch the toes
Therapeutic exercise is one of the core management strategies for osteoarthritis recommended in the draft NICE guidance. | GETTY IMAGES

Osteoarthritis is the most common form of arthritis and affects an estimated 7.4 million people in England over the age of 45 years.

NICE states that there is clinical evidence to show that when people with osteoarthritis are offered tailored exercises, such as muscle strengthening and aerobic exercise, they can achieve good health outcomes.

Consequently, the core management strategies recommended in the draft guidance, which will update NICE guideline CG177 (published February 2014), are tailored therapeutic exercise (eg, local muscle strengthening, general aerobic fitness) and weight loss (if appropriate), along with information and support.

The draft guidance recommends that if pharmacological treatments are needed to manage osteoarthritis, they should be used alongside non-pharmacological treatments and to support therapeutic exercise, at the lowest effective dose for the shortest possible period of time.

Topical NSAIDs first option

People should be offered a topical NSAID or an oral NSAID if topical therapy is ineffective or unsuitable.

NICE recommends that people are not routinely offered weak opioids unless for short-term pain relief and if all other pharmacological treatments are contraindicated, not tolerated or ineffective. Strong opioids should not be offered.

The draft guidance also recommends that paracetamol, glucosamine and intra-articular hyaluronan injections are not routinely offered to people with osteoarthritis. Intra-articular corticosteroid injections may be considered for short-term relief when other pharmacological treatments are ineffective or unsuitable.

Dr Paul Chrisp, director for the Centre for Guidelines at NICE said: "Whilst topical and sometimes oral NSAIDs remain an important treatment option for osteoarthritis, we have taken the decision to not recommend some painkillers such as paracetamol and some opioids for osteoarthritis. This is because new evidence has shown there was little or no benefit to people's quality of life, pain or psychological distress and particularly in the case of strong opioids, there was evidence that they can cause harm in the longer term, including possible addiction."

Clinical diagnosis may be sufficient

The draft guidance also recommends that osteoarthritis can be diagnosed clinically without investigations in people who are aged 45 and over with activity-related joint pain, and who have either no morning joint-related stiffness or morning stiffness that lasts for half an hour or less. It adds that imaging should not be used routinely unless there are atypical features or features that indicate an alternative or additional diagnosis. 

The draft guidance is out for consultation until 14th June and is expected to be published in October 2022.

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