1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See About this guideline for details.

1.1 Diagnosis

1.1.1 Diagnose osteoarthritis clinically without investigations if a person:

  • is 45 or over and

  • has activity-related joint pain and

  • has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes. [new 2014]

1.1.2 Be aware that atypical features, such as a history of trauma, prolonged morning joint-related stiffness, rapid worsening of symptoms or the presence of a hot swollen joint, may indicate alternative or additional diagnoses. Important differential diagnoses include gout, other inflammatory arthritides (for example, rheumatoid arthritis), septic arthritis and malignancy (bone pain). [new 2014]

1.2 Holistic approach to osteoarthritis assessment and management

1.2.1 Assess the effect of osteoarthritis on the person's function, quality of life, occupation, mood, relationships and leisure activities. Use figure 1 as an aid to prompt questions that should be asked as part of the holistic assessment of a person with osteoarthritis. [2008]

Holistic assessment of a person with osteoarthritis (OA)

Figure 1 Holistic assessment of a person with osteoarthritis (OA)

This figure is intended as an 'aide memoir' to provide a breakdown of key topics that are of common concern when assessing people with osteoarthritis. For most topics there are a few suggested specific points that are worth assessing. Not every topic will be of concern for everyone with osteoarthritis, and there are other topics that may warrant consideration for particular people.

1.2.2 Agree a plan with the person (and their family members or carers as appropriate) for managing their osteoarthritis. Apply the principles in Patient experience in adult NHS services (NICE clinical guidance 138) in relation to shared decision-making. [new 2014]

1.2.3 Take into account comorbidities that compound the effect of osteoarthritis when formulating the management plan. [2008]

1.2.4 Discuss the risks and benefits of treatment options with the person, taking into account comorbidities. Ensure that the information provided can be understood. [2008]

1.2.5 Offer advice on the following core treatments to all people with clinical osteoarthritis.

  • Access to appropriate information (see recommendation 1.3.1).

  • Activity and exercise (see recommendation 1.4.1).

  • Interventions to achieve weight loss if the person is overweight or obese (see recommendation 1.4.3 and Obesity [NICE clinical guideline 43]). [2008, amended 2014]

1.3 Education and self-management

Patient information

1.3.1 Offer accurate verbal and written information to all people with osteoarthritis to enhance understanding of the condition and its management, and to counter misconceptions, such as that it inevitably progresses and cannot be treated. Ensure that information sharing is an ongoing, integral part of the management plan rather than a single event at time of presentation. [2008]

Patient self-management interventions

1.3.2 Agree individualised self-management strategies with the person with osteoarthritis. Ensure that positive behavioural changes, such as exercise, weight loss, use of suitable footwear and pacing, are appropriately targeted. [2008]

1.3.3 Ensure that self-management programmes for people with osteoarthritis, either individually or in groups, emphasise the recommended core treatments (see recommendation 1.2.5), especially exercise. [2008]

Thermotherapy

1.3.4 The use of local heat or cold should be considered as an adjunct to core treatments. [2008]

1.4 Non-pharmacological management

Exercise and manual therapy

1.4.1 Advise people with osteoarthritis to exercise as a core treatment (see recommendation 1.2.5), irrespective of age, comorbidity, pain severity or disability. Exercise should include:

  • local muscle strengthening and

  • general aerobic fitness.

    It has not been specified whether exercise should be provided by the NHS or whether the healthcare professional should provide advice and encouragement to the person to obtain and carry out the intervention themselves. Exercise has been found to be beneficial but the clinician needs to make a judgement in each case on how to effectively ensure participation. This will depend upon the person's individual needs, circumstances and self-motivation, and the availability of local facilities. [2008]

1.4.2 Manipulation and stretching should be considered as an adjunct to core treatments, particularly for osteoarthritis of the hip. [2008]

Weight loss

1.4.3 Offer interventions to achieve weight loss[1] as a core treatment (see recommendation 1.2.5) for people who are obese or overweight. [2008]

Electrotherapy

1.4.4 Healthcare professionals should consider the use of transcutaneous electrical nerve stimulation (TENS)[2] as an adjunct to core treatments for pain relief. [2008]

Nutraceuticals

1.4.5 Do not offer glucosamine or chondroitin products for the management of osteoarthritis. [2014]

Acupuncture

1.4.6 Do not offer acupuncture for the management of osteoarthritis. [2014]

Aids and devices

1.4.7 Offer advice on appropriate footwear (including shock-absorbing properties) as part of core treatments (see recommendation 1.2.5) for people with lower limb osteoarthritis. [2008]

1.4.8 People with osteoarthritis who have biomechanical joint pain or instability should be considered for assessment for bracing/joint supports/insoles as an adjunct to their core treatments. [2008]

1.4.9 Assistive devices (for example, walking sticks and tap turners) should be considered as adjuncts to core treatments for people with osteoarthritis who have specific problems with activities of daily living. If needed, seek expert advice in this context (for example, from occupational therapists or Disability Equipment Assessment Centres). [2008]

Invasive treatments for knee osteoarthritis

1.4.10 Do not refer for arthroscopic lavage and debridement[3] as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (as opposed to morning joint stiffness, 'giving way' or X-ray evidence of loose bodies). [2008, amended 2014]

1.5 Pharmacological management

NICE intends to undertake a full review of evidence on the pharmacological management of osteoarthritis. This will start after a review by the MHRA (Medicines and Healthcare Products Regulatory Agency) of the safety of over-the-counter analgesics is completed. For more information, see the Introduction.

In the meantime, the original recommendations (from 2008) remain current advice. However, the Guideline Development Group (GDG) would like to draw attention to the findings of the evidence review on the effectiveness of paracetamol that was presented in the consultation version of the guideline. That review identified reduced effectiveness of paracetamol in the management of osteoarthritis compared with what was previously thought. The GDG believes that this information should be taken into account in routine prescribing practice until the planned full review of evidence on the pharmacological management of osteoarthritis is published (see the NICE website for further details).

Oral analgesics

1.5.1 Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatments (see recommendation 1.2.5); regular dosing may be required. Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclo-oxygenase 2 (COX-2) inhibitors or opioids. [2008]

1.5.2 If paracetamol or topical NSAIDs are insufficient for pain relief for people with osteoarthritis, then the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in older people. [2008]

Topical treatments

1.5.3 Consider topical NSAIDs for pain relief in addition to core treatments (see recommendation 1.2.5) for people with knee or hand osteoarthritis. Consider topical NSAIDs and/or paracetamol ahead of oral NSAIDs, COX-2 inhibitors or opioids. [2008]

1.5.4 Topical capsaicin should be considered as an adjunct to core treatments for knee or hand osteoarthritis. [2008]

1.5.5 Do not offer rubefacients for treating osteoarthritis. [2008]

NSAIDs and highly selective COX-2 inhibitors

Although NSAIDs and COX-2 inhibitors may be regarded as a single drug class of 'NSAIDs', these recommendations use the two terms for clarity and because of the differences in side-effect profile.

1.5.6 Where paracetamol or topical NSAIDs are ineffective for pain relief for people with osteoarthritis, then substitution with an oral NSAID/COX-2 inhibitor should be considered. [2008]

1.5.7 Where paracetamol or topical NSAIDs provide insufficient pain relief for people with osteoarthritis, then the addition of an oral NSAID/COX-2 inhibitor to paracetamol should be considered. [2008]

1.5.8 Use oral NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest possible period of time. [2008]

1.5.9 When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg). In either case, co-prescribe with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost. [2008]

1.5.10 All oral NSAIDs/COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal, liver and cardio-renal toxicity; therefore, when choosing the agent and dose, take into account individual patient risk factors, including age. When prescribing these drugs, consideration should be given to appropriate assessment and/or ongoing monitoring of these risk factors. [2008]

1.5.11 If a person with osteoarthritis needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2 inhibitor (with a PPI) if pain relief is ineffective or insufficient. [2008]

Intra-articular injections

1.5.12 Intra-articular corticosteroid injections should be considered as an adjunct to core treatments for the relief of moderate to severe pain in people with osteoarthritis. [2008]

1.5.13 Do not offer intra-articular hyaluronan injections for the management of osteoarthritis. [2014]

1.6 Referral for consideration of joint surgery

1.6.1 Clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core (non-surgical) treatment options (see recommendation 1.2.5). [2008]

1.6.2 Base decisions on referral thresholds on discussions between patient representatives, referring clinicians and surgeons, rather than using scoring tools for prioritisation. [2008, amended 2014]

1.6.3 Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment. [2008, amended 2014]

1.6.4 Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain. [2008, amended 2014]

1.6.5 Patient-specific factors (including age, sex, smoking, obesity and comorbidities) should not be barriers to referral for joint surgery. [2008, amended 2014]

1.6.6 When discussing the possibility of joint surgery, check that the person has been offered at least the core treatments for osteoarthritis (see recommendation 1.2.5), and give them information about:

  • the benefits and risks of surgery and the potential consequences of not having surgery

  • recovery and rehabilitation after surgery

  • how having a prosthesis might affect them

  • how care pathways are organised in their local area. [new 2014]

1.7 Follow-up and review

1.7.1 Offer regular reviews to all people with symptomatic osteoarthritis. Agree the timing of the reviews with the person (see also recommendation 1.7.2). Reviews should include:

  • monitoring the person's symptoms and the ongoing impact of the condition on their everyday activities and quality of life

  • monitoring the long-term course of the condition

  • discussing the person's knowledge of the condition, any concerns they have, their personal preferences and their ability to access services

  • reviewing the effectiveness and tolerability of all treatments

  • support for self-management. [new 2014]

1.7.2 Consider an annual review for any person with one or more of the following:

  • troublesome joint pain

  • more than one joint with symptoms

  • more than one comorbidity

  • taking regular medication for their osteoarthritis. [new 2014]

1.7.3 Apply the principles in Patient experience in adult NHS services (NICE clinical guidance 138) with regard to an individualised approach to healthcare services and patient views and preferences. [new 2014]



[2] TENS machines are generally loaned to the person by the NHS for a short period, and if effective the person is advised where they can purchase their own.

[3] This recommendation is a refinement of the indication in Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis (NICE interventional procedure guidance 230 [2007]). The clinical and cost-effectiveness evidence for this procedure was reviewed for the original guideline (published in 2008), which led to this more specific recommendation on the indication for which arthroscopic lavage and debridement is judged to be clinically and cost effective.

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