What Can GPs Learn from the New NICE Guideline on Osteoarthritis?

Dr David Stephens Gives Practical Advice for GPs on Diagnosing, Managing, and Referring Patients with Osteoarthritis Based on New NICE Guidance

Osteoarthritis is the most common joint disease worldwide, affecting an estimated 10% of men and 18% of women aged over 60 years,¹ and is a common presentation in general practice. In 2013, an estimated 8.75 million people in the UK aged over 45 years sought some kind of treatment for osteoarthritis.¹

In October 2022, NICE published NICE Guideline 226 (NG226), Osteoarthritis in over 16s: diagnosis and management, which updates and replaces its previous guideline on the topic.² In NG226, NICE suggests that clinicians should be conservative with medication and use it as a second-line treatment, with first-line management consisting of exercise, physical therapy and, if the patient is overweight, weight reduction.² The guideline also covers consideration of referral for joint replacement surgery.²

There is insufficient evidence that medical treatments can halt or significantly change the progression of osteoarthritis, although certain treatments—including physical therapies, anti-inflammatories, and joint injections—can ameliorate symptoms, and surgical joint replacements, generally considered a last resort, can be seen as a cure.^2–4 In light of this, clinicians should recognise that NICE guidance is primarily evidence based but, when evidence is scarce or absent, NICE can sometimes give guidance that may be described as ‘eminence based’, meaning that it was developed through the consensus of experts.

Definition and Mechanism of Osteoarthritis

NICE defines osteoarthritis as ‘a disorder of synovial joints [that] occurs when damage triggers repair processes leading to structural changes within a joint.’⁵ The original damage may occur through repeated, excessive loading and stress on a joint over time, or as a result of injury.⁵ Regardless, it is the repair process that triggers the symptoms of osteoarthritis; if repair is incomplete, this may result in chronic pain, stiffness, and inflammation.⁵ Typical features include loss of cartilage, excess bone growth, and mild inflammation (particularly of the synovial membrane).⁵ Although any synovial joint can be affected, osteoarthritis mainly affects a person’s knees, hips, or the small joints of their hands.⁵

An understanding of the definition of osteoarthritis and how the repair process causes the condition—among clinicians, but also among patients—is helpful when considering its risk factors, diagnosis, and management.

Risk Factors

The cause of osteoarthritis is unclear, but there is evidence—from a study of monozygotic twins in particular, but also from other research—that genetics play a role in its aetiology.^6,7 Other risk factors that appear to play a role in the pathogenesis of osteoarthritis include:^6,8

• increasing age
• female sex
• obesity, which increases risk in weight-bearing joints in particular
• high and low bone density
• joint injury, damage, malalignment, or abnormality
• joint laxity or reduced muscle strength
• exercise or occupational stresses, such as those involving joint load, repetitive movements, or prolonged lifting and standing
• damage from other joint diseases, such as gout.

Diagnosis

NICE recommends diagnosing osteoarthritis clinically (without imaging) in people who:²

• are older than 45 years
• have activity-related joint pain
• have either no joint-related stiffness in the morning, or joint-related stiffness that lasts no longer than 30 minutes.

NG226 advises clinicians not to order imaging of a joint for diagnostic purposes unless there are atypical features or suspicion of an alternative diagnosis—these features could include a history of recent trauma, prolonged joint-related stiffness in the morning, rapid worsening of symptoms, deformity, a hot swollen joint, or concerns suggesting infection or malignancy.² Alternative diagnoses should always be considered²—a substantial list can be found here: bit.ly/3YxCP2i.

See Figures 1 and 2 for a classic presentation of osteoarthritis of the hand.

Figure 1: Osteoarthritis of the Hand with Distal and Proximal Interphalangeal Joint Swelling

Figure 2: Flare Up of Osteoarthritis in the Distal Interphalangeal Joint of the Index Finger

Management

Osteoarthritis management is generally based on symptoms and physical function; the main aspects are the provision of information and support, the promotion of tailored exercise and weight management, and the treatment of symptoms.² Importantly, NICE recommends that clinicians should practise shared decision making when supporting patients with the condition, and should consider how management may differ for patients with multimorbidity.² Figure 3 outlines NICE's recommended approach.^2,9

Figure 3: NICE Recommendations on the Management of Osteoarthritis⁹

Information and Support

NG226 emphasises the importance of providing information about osteoarthritis not only to the patient, but also to their family and carers, as this helps them to better understand the condition and take an active part in its management.² This information should be delivered in accessible formats, in ways that reach all patient groups to promote active participation in care—including patients with different cultures or languages, and patients who have difficulty understanding ordinary verbal or written communication.^2,10

Discussions between a clinician and a patient should cover:²

• diagnosis, and why it can usually be done clinically without the need for imaging
• how management works, and why it is guided by symptoms and physical function
• the main ways in which osteoarthritis is treated, namely therapeutic exercise and weight management.

Box 1 contains some examples of useful sources of information and support for patients.

Nonpharmacological Management

The nonpharmacological management of osteoarthritis generally consists of a combination of therapeutic exercise, weight management, manual therapy, and the use of mobility aids.²

Tailored Therapeutic Exercise

Tailored therapeutic exercise, with consideration of supervised sessions to increase adherence and foster regular exercise habits, is the primary method recommended by NICE for managing osteoarthritis.² Initially, this exercise may cause pain and discomfort, but it will ultimately benefit the joints, particularly with long-term adherence.² If possible, combining therapeutic exercise with an explanation of its benefits for symptoms and quality of life, as well as an educational programme, can be particularly effective.²

Weight Reduction (If Overweight)

Although the available evidence is limited, NICE acknowledges that weight loss is generally associated with improved symptoms and quality of life for people with osteoarthritis, particularly those with knee osteoarthritis.² Therefore, NG226 recommends advising patients who are overweight or obese to lose weight, and supporting them to choose a weight-loss goal.² Although any weight loss is likely to help, it is worth noting and, if appropriate, explaining to patients that losing 10% of their body weight is likely to be more beneficial than losing 5%.²

Manual Therapy

In its evidence review, NG226’s Guideline Development Group acknowledged that there is insufficient evidence to recommend the use of manual therapy alone.² However, the committee decided that there was enough evidence of its benefits when combined with therapeutic exercise to recommend considering its use alongside exercise specifically in people with hip and knee osteoarthritis.² Manual therapy can include manipulation, mobilisation, or soft-tissue techniques.²

Mobility Aids

Walking aids include walking sticks, crutches, walking frames, and rollators—use of these aids can be considered for patients with lower-limb osteoarthritis.² Insoles, braces, tape, splints, and supports can also be helpful for joint stability, but are recommended only if the following are all true:²

• the patient has joint instability or abnormal biomechanical loading
• therapeutic exercise would be ineffective or impossible without this kind of aid
• the aid would likely improve the patient’s movement and function.

Acupuncture and Electrotherapy

NICE stresses that clinicians should not recommend acupuncture, dry needling, or electrotherapy treatments for the management of osteoarthritis.²

Pharmacological Therapy

If pharmacological treatments are required, NICE recommends using them in conjunction with nonpharmacological interventions, and for the shortest possible time at the lowest possible dose.² Regarding choice of treatment, NICE suggests the following:²

• firstly, offer a topical nonsteroidal anti-inflammatory drug (NSAID)—NICE notes that there is stronger evidence of benefit in patients with knee osteoarthritis, so recommends topical NSAIDs more strongly for these patients than for those whose osteoarthritis affects other joints
• secondly, if topical methods are unsuitable or ineffective, consider an oral NSAID, taking into account potential gastrointestinal, renal, liver, and cardiovascular toxicities and any risk factors, including age, pregnancy, current medication, and comorbidities
  • NICE also recommends offering gastroprotective treatment for people with osteoarthritis taking an oral NSAID
• thirdly, for flare ups and infrequent short-term pain relief, clinicians can offer paracetamol or weak opioids; however, NICE states that there is no strong evidence of benefit for paracetamol in patients with osteoarthritis
• finally, when other pharmacological treatments are ineffective or unsuitable, or to support therapeutic exercise, NICE recommends considering intra-articular corticosteroid injections, as there is some emerging evidence of their benefit—it is emphasised that these are only for short-term relief, however, and to support other methods of management
• all other pharmacological treatments are not recommended, notably intra-articular hyaluronan injections, glucosamine, and strong opioids (see the section, Inadvisable Actions).

Prescribing information for topical NSAIDs can be found in the NICE Clinical Knowledge Summary on this topic (bit.ly/3I24jWw),¹¹ with further information on the British National Formulary website—bnf.nice.org.uk.

Referral

Hip, knee, and shoulder replacements are indicated if nonsurgical management is ineffective or unsuitable and—crucially—the person’s joint symptoms are substantially affecting their quality of life.² Clinicians should make referral decisions based on clinical assessment, rather than numerical scoring systems.² NICE emphasises that there should be no discrimination or exclusion of patients when it comes to referring them for joint replacement, particularly regarding a particular characteristic such as weight, age, sex, gender identity, smoking status, or comorbidities,² even though there are long NHS waiting lists for elective surgery.¹²

Inadvisable Actions

NG226 lists some inadvisable actions that clinicians managing patients with osteoarthritis should take care to avoid. Acupuncture or dry needling should not be offered to patients to manage osteoarthritis.² Similarly, the following electrotherapy treatments should not be used in people with osteoarthritis because there is insufficient evidence of benefit:²

• transcutaneous electrical nerve stimulation
• ultrasound therapy
• interferential therapy
• laser therapy
• pulsed short-wave therapy
• neuromuscular electrical stimulation.

In addition, as mentioned above, imaging should not routinely be used to diagnose osteoarthritis unless there are atypical features or features that suggest an alternative or additional diagnosis; it should also not routinely be used for follow up or to guide nonsurgical management of osteoarthritis.² The following treatments are advised against as well:²

• glucosamine
• strong opioids
• intra-articular hyaluronan injections
• arthroscopic lavage and debridement.

Research Priorities: Questions Yet to Be Answered About Osteoarthritis

In the guideline, NICE suggests 13 areas for osteoarthritis research, framed as questions that still need to be answered.² These questions are unlikely to be answered any time soon, but for a condition like osteoarthritis (where the evidence is so unclear), NICE’s areas for research are worth noting—in some ways, the lack of evidence in certain areas gives clinicians greater scope for clinical judgement.

Formulating these areas for research is a key aspect of NICE’s work—the answers will give clinicians a better basis for caring for patients. NICE’s recommendations for research can also influence national research funding—the National Institute for Health and Care Research works closely with NICE, for example, regularly funding research in its identified areas.¹³

The four key research priorities identified in NG226 are:²

1. Exercise—‘what is the clinical and cost effectiveness of supervised group and individual exercise compared with unsupervised exercise for people with osteoarthritis?’
2. Devices—‘what is the clinical and cost effectiveness of devices compared with usual care for the management of painful foot and/or ankle osteoarthritis?’
3. Topical medicines—‘what is the clinical and cost effectiveness of topical [NSAIDs] and topical capsaicin for osteoarthritis-affected joints other than the knee?’
4. Follow-up strategies—‘what is the clinical and cost effectiveness of patient-initiated follow up compared with routine follow up for people with osteoarthritis?’

Further recommendations for research consider other aspects of managing osteoarthritis, including manual therapy, electroacupuncture, footwear, intra-articular injections, referral criteria, and imaging.²

Conclusion

Although osteoarthritis is a common condition, there is still a lack of strong evidence to support most management techniques, and no evidence of treatments that change the progress of the disease apart from joint replacement. With this in mind, NICE’s new guidance prioritises information sharing and nonpharmacological treatments, particularly therapeutic exercise, to improve patients’ lives, and emphasises the limits of pharmacological treatment. Hopefully, research in the areas identified by NICE will help to guide the future management of this disease.