Osteoarthritis is the most common form of arthritis in the UK and presents with varying symptoms, including pain and stiffness. This month Nice updated its guidelines on the issue to include new recommendations on exercise and pain management. So what do pharmacists need to know about the condition?
1. Diagnosis can be straightforward
Osteoarthritis should be diagnosed without investigation if a person is aged 45 years or older, has activity-related joint pain and has either no morning stiffness or stiffness that lasts no longer than 30 minutes on waking.
2. It's not ‘untreatable'
Nice names sharing information as an "integral" part of managing osteoarthritis and calls on healthcare professionals to remove the misconception that the condition will inevitably progress and is therefore untreatable. "There's a common but mistaken belief that osteoarthritis is an inevitable part of ageing and that it will get worse, but that's not the case," stresses Mark Baker, centre for clinical practice director at Nice.
3. Exercise is a core treatment
The latest Nice guidelines reiterate that exercise and weight loss are the core treatments in managing osteoarthritis. Health professionals should encourage local muscle strengthening and aerobic exercise regardless of the patient's age, comorbidity, pain severity or disability to reduce pain. They should also give advice on weight loss to overweight and obese sufferers.
4. Paracetamol remains recommended
Nice still recommends paracetamol for additional pain relief, despite warning of the drug's potentially "limited benefit" last year. It suggests trying paracetamol and/or a topical non-steroidal anti-inflammatory (NSAID) as first-line pain management alongside exercise.
5. NSAIDs and opioids are second line
If paracetamol and topical NSAIDs don't work, healthcare professionals can recommend moving on to an oral NSAID, Cox-2 inhibitor or an opioid. NSAIDs and Cox-2 inhibitors should be used at the lowest effective dose for the shortest amount of time possible and taken in conjunction with a proton pump inhibitor. An opioid analgesic may be considered if the benefits outweigh the risks.
6. Over-80s are a grey area
In patients aged over 80, NSAIDs are frequently contraindicated. Very little data exists on the use of pharmacological and non-pharmacological treatments for this age group, so outcome and intervention studies are urgently needed.
7. Combination treatments are unexplored
Trials are needed to determine the effectiveness of combination treatments such as NSAIDs and opioids. It is not yet known whether they can provide a dual effect in relieving symptoms or target particular anatomical sites, and so are not yet recommended in clinical practice.
8. Recommend alternative treatments with caution
The latest Nice guidance advises against recommending acupuncture, glucosamine or chondroitin supplements for the management of osteoarthritis. But healthcare professionals can suggest stretching, using a hot or cold compress, intra-articular corticosteroid injections and transcutaneous electrical nerve stimulation (TENS) in addition to core treatment. Wearing appropriate footwear such as shock-absorbing shoes, using insoles and walking sticks can help people with lower limb osteoarthritis.
9. Patients need regular reviews
Regular reviews should be offered to all people with symptoms of osteoarthritis, potentially in the form of an MUR. Personalised self-management plans should be drafted with the patient, not only looking at their medicines but also encouraging positive behavioural changes such as exercising, wearing appropriate footwear and losing weight.
10. Surgery is an option
If a person is experiencing pain that interferes with their daily life, despite core treatment and the use of analgesics, they should be referred so that joint surgery can be considered. The threshold for referral should be based on patient discussions. Factors such as a person's age, smoking status and obesity should not affect the decision.