Management of osteoarthritis

NICE have issued clinical guidance on the management of osteoarthritis ( CG177).

Osteoarthritis (OA) is by far the most common joint disorder. It is a major cause of pain and disability in the elderly. Pain is the most common symptom and still presents a major therapeutic challenge. OA pain is typically:

• insidious in onset, variable or intermittent over time ('good days, bad days')
• activity and weight bearing related, relieved by rest
• brief (less than 15 minutes) morning stiffness or 'gelling' after rest
• usually only one or a few joints affected

Take into account the patient's attitudes and knowledge, self-treatments, constitutional factors (e.g. obesity, muscle weakness, non-restorative sleep), co-morbid disease and its therapy, treatment availability and costs.

Options include:

• A prescription of exercise, e.g. quadriceps strengthening exercises, and general aerobic fitness.
• Weight loss.
• Address mechanical factors - activity modification, pacing, mobility aids, patella taping, footwear and orthoses.
• Analgesia.

NICE TA304 Arthritis of the hip (end stage) - hip replacement (total) and resurfacing arthroplasty (February 2014).

Analgesics in osteoarthritis

Local guidance on pain relief given below is similar to NICE guidance but places more emphasis on the type of osteoarthritis as topical preparations are only of significant benefit for small joint osteoarthritis.

1st step:

• Paracetamol
• Topical NSAID ± paracetamol for hand, knee or nodal OA
  • (see 10.4 Pain and inflammation in musculoskeletal disorders)

2nd step:

• Add codeine

3rd step:

• Oral NSAIDs or COX-ll inhibitors
  • (see 10.4 Pain and inflammation in musculoskeletal disorders)

4th step:

• Topical capsaicin for knee or nodal OA
  • (see 10.4 Pain and inflammation in musculoskeletal disorders)

5th step:

• Intra-articular corticosteroid injections
  • (see 10.5 Soft tissue and joint disorders and notes below)

Notes

1. Offer paracetamol for pain relief using regular dosing.
2. Consider topical NSAIDs either with paracetamol or instead of paracetamol in patients with OA localised to the hand or knee and for patients with nodal OA (Heberden's and Bouchard's nodes). Topical ibuprofen is the formulary choice. This should be tried before offering additional systemic drug therapy, but may not be suitable for some patients
3. NICE do not recommend use of rubefacients. However, some patients with nodal OA may find topical salicylate containing rubefacients beneficial. These are available OTC at less than the cost of a prescription charge.
4. Notes on chondroitin and glucosamine are available in section 10.1 Drugs used in rheumatic diseases and gout.

Intra-articular corticosteroid injections

See also general notes on local steroid injections and section 10.5 Soft tissue and joint disorders.

Guidance from the British Society of Rheumatology for the management of musculoskeletal and rheumatic conditions with corticosteroids during the Coronavirus (COVID-19) pandemic can be found here

Intra-articular injection of long-acting steroid (e.g. triamcinolone acetonide 40mg or methylprednisolone acetate 40mg) can give rapid, effective, but temporary relief of pain (acts within 24 hours, lasts 2-6 weeks). They may be appropriate for quick control of severe pain, or to tide someone over for a special event, or to temporarily control pain whilst longer-term interventions such as exercise are instituted. There are no clear predictors of response.

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