2022NICE guideline update: key points for the diagnosis and treatment of osteoarthritis Guidelines consensus

Osteoarthritis (OA) is a degenerative joint disease that seriously affects the quality of life of patients, placing a heavy burden
on patients, families and society.
OA not only causes joint pain, deformity, and dysfunction, but also significantly increases the risk of
cardiovascular events, lower extremity deep vein thromboembolism, hip fracture, and all-cause mortality.
According to literature reports, there are currently more than 300 million OA patients in the world, and the overall prevalence of primary OA in people over 40 years old in China has reached 46.
3%.

At the same time, with the continuous aging of China's population, the prevalence of OA has gradually increased
.
Therefore, standardized diagnosis and treatment of OA is of great significance
to clinical work and social development.

In recent years, China has successively formulated and released the "Chinese Osteoarthritis Pain Management Clinical Practice Guidelines (2020 Edition)", "Chinese Osteoarthritis Diagnosis and Treatment Guidelines (2021 Edition)" and "Expert Consensus on Osteoarthritis Clinical Drug Therapy" to promote the standardized diagnosis and treatment
of OA.
On October 19, the National Institute for Health and Care Excellence (NICE) released the "Guidelines for the diagnosis and management of osteoarthritis in people older than 16 years", giving the latest OA diagnosis and treatment recommendations
.
This article focuses on the NICE guidelines on the diagnosis, non-pharmacological treatment, pharmacotherapy, and surgical treatment recommendations for OA for the reader's benefit
.

Diagnostic recommendations

1.
Imaging tests are not required for clinical diagnosis of OA: ≥ 45 years old, with activity-related joint pain, and no morning stiffness, or the duration of morning stiffness does not exceed 30 minutes
.

2.
Do not routinely use imaging to diagnose OA
unless there are atypical features or features that suggest additional diagnosis.

Non-pharmacological treatments are recommended

kinesiatrics

1
.
For all patients with OA, exercise therapy (such as local muscle strengthening, aerobic fitness, etc.
) should be provided according to their needs.

2.
Consider supervised exercise therapy
for patients with OA.

3.
Explain to people with OA that joint pain may increase when they start exercising:

➤ Although it may cause pain or discomfort at first, consistent exercise is good for the joints

➤ Long-term adherence to an exercise program can reduce pain, improve physical performance and quality of life, thereby increasing the benefits of exercise

4.
Consider combining exercise therapy with educational programs or behavior change approaches in a structured treatment plan
.

Control your weight

5.
For OA patients who are overweight or obese:

➤ Advising them to lose weight will improve their quality of life and physical function, and reduce pain

➤ Support them in identifying a weight loss goal

Explain to them that losing as much weight as much as you want can be beneficial, but losing 10% of your weight may be better than losing 5%.

Manual therapy

6.
People considering manual therapy (such as manipulation, movement, or soft tissue techniques): People with hip or knee osteoarthritis that is done
in conjunction with exercise therapy.

7.
When discussing manual therapy, it should be explained to people with OA that there is insufficient evidence to support manual therapy alone for OA
.

acupuncture

8.
Do not treat OA
with acupuncture or dry needling.

electrotherapy

9.
Because there is insufficient evidence of benefit, do not offer any of the following electrotherapies to patients with OA:

➤ Transcutaneous Electrical Nerve Stimulation (TENS)

➤ Ultrasound therapy

➤ Interference wave therapy

➤ Laser therapy

➤ Pulse shortwave therapy

➤ Neuromuscular Electrical Stimulation (NMES)

Drug therapy is recommended

Topical, oral, and transdermal medications

1.
If medication is needed to control OA, use:

➤ Combination of non-pharmacological treatments to support the use of exercise therapy

➤ Use the lowest effective dose in the shortest possible time

2.
Provide topical non-steroidal anti-inflammatory drugs
for patients with knee osteoarthritis.

3.
For patients with OA involving other joints, topical nonsteroidal anti-inflammatory drugs
can be considered.

4.
If topical medications are ineffective or inappropriate, consider giving oral NSAIDs to patients with OA, and consider:

➤ Potential gastrointestinal, renal, hepatic and cardiovascular toxicity

➤ Any risk factors the patient may have, including age, pregnancy, available medications, and comorbidities

(Gastric protective therapy, such as proton pump inhibitors, for patients who are taking NSAIDs).

5.
Do not routinely prescribe paracetamol or weak opioids unless:

➤ Only for short-term pain relief

➤ All other drug treatments are contraindications, intolerance, or ineffective

6.
Do not provide glucosamine or strong opioids for OA patients
.

7.
If a patient with OA asks about glucosamine or strong opioids, the explanation is as follows:

➤ There is no strong evidence that glucosamine is beneficial to the human body

➤ The risks of potent opioids outweigh the benefits of treatment

8.
Make decisions with the patient whether to continue treatment
.
Determine the frequency of
review as clinically necessary.

Intra-articular injection

9.
Do not provide intra-articular injection of hyaluronic acid to treat OA
.

10.
When other drug treatments are ineffective or inappropriate, consider intra-articular injection of glucocorticoids, or enable exercise therapy
.
And explain to the patient that these methods can only achieve short-term remission (2-10 weeks).

Surgical treatment is recommended

1.
Joint replacement can be considered for patients with hip arthritis, knee arthritis or shoulder osteoarthritis if they have:

➤Joint symptoms (such as pain, stiffness, decreased function, or progressive joint deformity) seriously affect the quality of life of patients

➤ Non-surgical treatments (e.
g.
, exercise therapy, weight loss, pain relief) are ineffective or inappropriate

2.
When deciding to recommend a patient for joint replacement, clinical evaluation should be used rather than a numerical scoring system to assess
disease severity.

3.
Do not exclude OA patients from joint replacement for the following reasons:

Age, sex, smoking, comorbidities, overweight, or obesity (based on measurements such as body mass index [BMI]).

4.
When discussing joint replacement, explain to the patient that the risks of joint replacement may depend on the factors listed in the
3 items above.

5.
Do not provide arthroscopic lavage or debridement treatment
for OA patients.

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References:

1.
Joint Surgery Group, Orthopedic Branch of Chinese Medical Association, Osteoarthritis Group of Orthopedic Physician Branch of Chinese Medical Doctor Association, National Clinical Research Center for Geriatric Diseases (Xiangya Hospital), etc.
Guidelines for the diagnosis and treatment of osteoarthritis in China (2021 edition)[J].
Chinese Journal of Orthopology,2021,41(18):1291-1314.
DOI:10.
3760/cma.
j.
cn121113-20210624-00424.

2.
NICE guideline.
Published: 19 October 2022.
www.
nice.
org.
uk/guidance/ng226.