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National Institute for Health and Clinical Excellence (NICE)

Osteoarthritis
The care and management of osteoarthritis in adults

Osteoarthritis is the most common disease of the joints, and one of the most widespread of allchronic diseases. Frequently described as ‘wear and tear’, its prevalence increases steadily withage and by retirement age the associated radiological changes can be observed in over half thepopulation. Symptoms can vary from minimal to severe pain and stiffness, but overall thedisease is responsible for considerable morbidity and is a common reason for GP consultation.Unfortunately, it is also difficult to treat and inevitably a wide range of potential therapies havebeen advocated, both by conventional and complementary practitioners, and not necessarilywith strong supporting evidence.The high prevalence of osteoarthritis, the numerous forms of potential treatment and theuncertainty around these all make the disorder an excellent topic for a clinical guideline. The lackof evidence in some areas is a less favourable feature, and although this has presented somethingof a challenge, the GDG has risen to this admirably. As with all NICE guidelines, an exhaustiveliterature search has been performed and the papers identified in this process have been rigorouslyassessed. Where it is possible to make recommendations based on good evidence, the GDG havedone so; where evidence is not available or is weak, they have either made recommendations onthe basis of strong clinical consensus, or have advocated appropriate research.The guideline contains a number of recommendations which are not currently routine practicefor many clinicians. While the place of paracetamol in early pain management is confirmed, theguideline also suggests early consideration of topical non-steroidal anti-inflammatory drugs(NSAIDs) for knee and hand arthritis, and suggests that wherever systemic NSAIDs orcyclooxygenase-2 (COX-2) inhibitors are used, they should be coprescribed with cover from aproton pump inhibitor (PPI). This latter recommendation will surprise many, but with PPIsnow coming off patent, it is clearly backed up by our health economic analysis. The positive roleof exercise is emphasised in contrast to the natural inclination some might have to rest when ajoint is affected by osteoarthritis. The GDG has also not shied away from negative recommendations.They suggest that arthroscopic lavage and debridement is not suitable therapy forosteoarthritis except in clear instances where this is associated with mechanical locking; andthey do not recommend the use of intra-articular hyaluronans. Elsewhere, there is onlyrestricted support for the use of acupuncture.The process of producing a guideline is rarely straightforward and there have been occasionaldifficulties along the way. The GDG have navigated all these with good humour and a consistentdesire to evaluate all evidence as thoroughly as they possibly could in order to improve themanagement of this difficult condition. We at the NCC-CC are grateful to them for all of theirwork. The guideline is a tribute to their efforts and we hope and expect that it can be used bothto practical benefit and to raise the profile of this sometimes neglected condition.

Guidance type: Clinical Guideline
Date issued: Febbraio 2008

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