Osteoarthritis: care and management
Clinical guideline [CG177]Published date:
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.|
1.1.1Diagnose 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]
1.1.2Be 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]
1.2.1Assess 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. 
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.
1.2.2Agree 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]
1.2.3Take into account comorbidities that compound the effect of osteoarthritis when formulating the management plan. 
1.2.4Discuss the risks and benefits of treatment options with the person, taking into account comorbidities. Ensure that the information provided can be understood. 
1.2.5Offer 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]
1.3.1Offer 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. 
1.3.2Agree 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. 
1.3.3Ensure 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. 
1.4.1Advise 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. 
1.4.2Manipulation and stretching should be considered as an adjunct to core treatments, particularly for osteoarthritis of the hip. 
1.4.3Offer interventions to achieve weight loss as a core treatment (see recommendation 1.2.5) for people who are obese or overweight. 
1.4.4Healthcare professionals should consider the use of transcutaneous electrical nerve stimulation (TENS) as an adjunct to core treatments for pain relief. 
1.4.5Do not offer glucosamine or chondroitin products for the management of osteoarthritis. 
1.4.7Offer advice on appropriate footwear (including shock-absorbing properties) as part of core treatments (see recommendation 1.2.5) for people with lower limb osteoarthritis. 
1.4.8People 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. 
1.4.9Assistive 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). 
1.4.10Do not refer for arthroscopic lavage and debridement 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]
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).
1.5.1Healthcare 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. 
1.5.2If 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. 
1.5.3Consider 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. 
1.5.4Topical capsaicin should be considered as an adjunct to core treatments for knee or hand osteoarthritis. 
1.5.5Do not offer rubefacients for treating osteoarthritis. 
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.
1.5.6Where 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. 
1.5.7Where 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. 
1.5.8Use oral NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest possible period of time. 
1.5.9When 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. 
1.5.10All 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. 
1.5.11If 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. 
1.5.12Intra-articular corticosteroid injections should be considered as an adjunct to core treatments for the relief of moderate to severe pain in people with osteoarthritis. 
1.5.13Do not offer intra-articular hyaluronan injections for the management of osteoarthritis. 
1.6.1Clinicians 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). 
1.6.2Base decisions on referral thresholds on discussions between patient representatives, referring clinicians and surgeons, rather than using scoring tools for prioritisation. [2008, amended 2014]
1.6.3Consider 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]
1.6.4Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain. [2008, amended 2014]
1.6.5Patient-specific factors (including age, sex, smoking, obesity and comorbidities) should not be barriers to referral for joint surgery. [2008, amended 2014]
1.6.6When 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]
1.7.1Offer 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]
1.7.2Consider 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]
1.7.3Apply 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]
 See Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children (NICE clinical guideline 43).
 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.
 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 ). 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.
2 Research recommendations
- 2.1 Treatments for osteoarthritis in very old people
- 2.2 Combinations of treatments for osteoarthritis
- 2.3 Treating common presentations of osteoarthritis for which there is little evidence
- 2.4 Biomechanical interventions in the management of osteoarthritis
- 2.5 Treatments that modify joint structure in people with osteoarthritis
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group’s full set of research recommendations is detailed in the full guideline.
What are the short-term and long-term benefits of non-pharmacological and pharmacological treatments for osteoarthritis in very old people (for example, aged 80 years and older)?
Very little data exist on the use of pharmacological and non-pharmacological treatments for osteoarthritis in very old people. This is highly relevant, not only because of the ageing population but also because of the high incidence of comorbidities in this population – osteoarthritis may be one of many health problems affecting function, and this may influence the appropriateness of management options. The acceptability, nature and setting for exercise strategies for this population is one area suggested for further study. Any non-pharmacological intervention for which a reduction in the need for drug treatment can be demonstrated is desirable. NSAIDs are frequently contraindicated in older people with comorbidities (such as renal failure, cardiovascular or gastrointestinal intolerance), and effective pharmacological options for this group warrant further study. Outcome and intervention studies are also needed for very old people in whom joint replacement surgery is not recommended because of risks associated with comorbidities.
What are the benefits of combinations of treatments for osteoarthritis, and how can these be included in clinically useful, cost-effective algorithms for long-term care?
Most people with osteoarthritis have symptoms for many years, and over this time they will receive several treatments, sometimes in combination. This may involve a combination of non-pharmacological and pharmacological treatments, such as using a walking stick and taking analgesics at the same time. Perhaps more commonly, a person may take different analgesics at the same time (for example, NSAIDs and opioids). However, most of the osteoarthritis trial evidence only evaluates single treatments, and often such trials are of short duration (for example, 6 weeks). We need to understand the benefits of combination treatments relevant to particular anatomical sites of osteoarthritis (for example, hand compared with knee) and whether particular combinations provide synergistic benefit in terms of symptom relief. Also needed is an understanding of how combinations of treatments can be included in algorithms (for example, dose escalation or substitution designs) for use in clinical practice. Trials to address this area may need to utilise complex intervention methodologies with health economic evaluations, and will need to stratify for comorbidities that affect the use of a particular intervention.
What are effective treatments for people with osteoarthritis who have common but poorly researched problems, such as pain in more than one joint or foot osteoarthritis?
Although people with osteoarthritis typically have symptoms that affect one joint at any particular time, there are still many people, especially older people, who have more than one painful joint. For example, it is common for osteoarthritis to affect both knees, or for a person to have pain in one knee and in one or more small joints such as the base of the thumb or the big toe. The mechanisms that cause pain may differ in people with one affected joint compared with those who have pain in several joints. For example, altered use because of pain in one joint often leads to increased mechanical stress and pain at other sites, and having chronic pain at one site can influence the experience of pain elsewhere in the body. However, almost all trials of treatments for osteoarthritis focus on a single joint, and if a participant has bilateral symptoms or additional symptoms at a different joint site only one ‘index’ joint (the most painful) is assessed. Whether systemic treatments for osteoarthritis work less well if a person has more than one painful site, and whether local treatment of one joint (for example, injection of corticosteroid into a knee) can lead to benefits at other sites (for example, the foot) remains unknown. A further caveat to current research evidence is that most trials focus on treatment of knee osteoarthritis, and to a lesser extent hip or hand osteoarthritis, but there are very few trials that examine other prevalent sites of osteoarthritis such as the first metatarsophalangeal (bunion) joint, the mid-foot joints, the ankle or the shoulder. Trials should be undertaken to determine the efficacy of available treatments, both local and systemic, at such sites. New outcome instruments to measure pain, stiffness and function specific to osteoarthritis at each site may need to be developed and validated for use in such trials.
Which biomechanical interventions (such as footwear, insoles, braces and splints) are most beneficial in the management of osteoarthritis, and in which subgroups of people with osteoarthritis do they have the greatest benefit?
In many people, osteoarthritis is made worse by weight-bearing or biomechanical forces through an affected joint. For example, base of thumb pain may be worse with grabbing and lifting items. Local support for the joint, in this case via a thumb splint, may improve pain and function. A large range of devices are available to help people with osteoarthritis in different joints, but there are very few trials to demonstrate their efficacy, and in particular little data to guide healthcare professionals on which people would benefit most from these aids. For example, there are many knee braces available, but few well designed randomised controlled trials of their efficacy, and few suggestions for clinicians on which patient subgroups might benefit from their use. Trials in the device area require careful attention to design issues such as the selection of control or sham interventions, blinded assessments and the choice of validated outcome measures that reflect the specific joint or functional ability being targeted.
2.5 Treatments that modify joint structure in people with osteoarthritis
In people with osteoarthritis, are there treatments that can modify joint structure, resulting in delayed structural progression and improved outcomes?
Why this is important
There is evidence from observational studies that factors affecting structural joint components, biomechanics and inflammation in and around the joint influence the progression of osteoarthritis. Symptoms appear to be more closely linked to structure than was once thought, so preventing progression of the structural deterioration of a joint is expected to deliver symptomatic benefits for people with osteoarthritis, as well as delaying joint replacement in some. There have been published randomised controlled trials with interventions targeting structural components of cartilage (glucosamine sulphate) and bone (strontium ranelate). However, several limitations have been identified with the glucosamine sulphate studies, and it is unclear whether cardiovascular concerns will prevent approval of strontium ranelate for treating osteoarthritis. Randomised, placebo-controlled trials of adequate power and duration (related to the structural end point under consideration) should be undertaken to determine the benefits and side effects of agents with disease-modifying osteoarthritis drug potential for treating both hip and knee osteoarthritis (separately). Appropriate structural end points may include progression of radiographic joint space narrowing or MRI features of osteoarthritis. Associated clinical end points could include measures of pain, function and health-related quality of life. Studies should also include rates of subsequent joint replacement (preferably maintaining original blinding, even if extensions are open label). Later phase trials should include a health economic evaluation.
NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.
|How this guideline was developed
NICE commissioned the National Clinical Guideline Centre to develop this guideline. The Centre established a Guideline Development Group (see section 4), which reviewed the evidence and developed the recommendations.
The methods and processes for developing NICE clinical guidelines are described in The guidelines manual.
Details are correct at the time of publication of the guideline (February 2014). Further information is available on the NICE website.
- Minimally invasive total hip replacement. NICE interventional procedure guidance 363 (2010).
- Shoulder resurfacing arthroplasty. NICE interventional procedure guidance 354 (2010).
- Mini-incision surgery for total knee replacement. NICE interventional procedure guidance 345 (2010).
- Depression in adults with a chronic physical health problem. NICE clinical guideline 91 (2009).
- Total prosthetic replacement of the temporomandibular joint. NICE interventional procedure guidance 329 (2009).
- Individually magnetic resonance imaging-designed unicompartmental interpositional implant insertion for osteoarthritis of the knee. NICE interventional procedure guidance 317 (2009).
- Rheumatoid arthritis. NICE clinical guideline 79 (2009).
- Total wrist replacement. NICE interventional procedure guidance 271 (2008)
- Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis. NICE interventional procedure guidance 230 (2007).
- Obesity. NICE clinical guideline 43 (2006).
- Metatarsophalangeal joint replacement of the hallux. NICE interventional procedure guidance 140 (2005).
- Artificial trapeziometacarpal joint replacement for end-stage osteoarthritis. NICE interventional procedure guidance 111 (2005).
- Artificial metacarpophalangeal and interphalangeal joint replacement for end-stage arthritis. NICE interventional procedure guidance 110 (2005).