1. Osteoarthritis Implementing NICE guidance 2008 NICE clinical guideline 59

2. What this presentation covers Background Holistic assessment and targeting treatment Key priorities for implementation -Core treatment -Adjuncts to core therapy Costs and savings Discussion Find out more

3. Background Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. It is the most common form of arthritis and one of the leading causes of pain and disability worldwide. It is not caused by ageing and does not necessarily deteriorate. It is a metabolically active repair process which is slow and can result in a structurally altered but symptom-free joint.

4. Holistic assessment A holistic approach to osteoarthritis assessment and management is needed. Healthcare professionals should assess the effect of osteoarthritis on the individual’s function, quality of life, occupation, mood, relationships, and leisure activities.

5. Targeting treatment education, advice, information access strengthening exercise aerobic fitness training weight loss if overweight/obese topical NSAIDs paracetamol supports and braces intra-articular corticosteroid injections opioids joint arthroplasty oral NSAIDs including COX-2 inhibitors TENS local heat and cold capsaicin manual therapy (manipulation and stretching) assistive devices shock-absorbing shoes or insoles

6. Core treatment Exercise should be a core treatment for people with osteoarthritis, irrespective of age, comorbidity, pain severity or disability. Exercise should include: local muscle strengthening, and general aerobic fitness.

7. Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatment; 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. Adjunct to core therapy: paracetamol

8. Healthcare professionals should consider offering topical NSAIDs for pain relief in addition to core treatment for people with knee or hand osteoarthritis. Topical NSAIDs and/or paracetamol should be considered ahead of oral NSAIDs, COX-2 inhibitors or opioids. Adjunct to core therapy: topical treatments

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, these should be co-prescribed with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost. Adjunct to core therapy: Oral NSAID/Cox-2 inhibitors

10. Referral for joint replacement surgery should be considered for people with osteoarthritis who experience joint symptoms that have a substantial impact on their quality of life and are refractory to non-surgical treatment. Referral should be made before there is prolonged and established functional limitation and severe pain. Adjunct to core therapy: referral criteria for surgery

11. Referral for arthroscopic lavage and debridement should not be offered as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (not gelling, ‘giving way’ or X-ray evidence of loose bodies). Adjunct to core therapy: invasive treatments for knee osteoarthritis

12. Costs and savings per 100,000 population Recommendations with significant costs Costs (£ per year) Topical NSAIDs18,000 Proton pump inhibitors23,000 Estimated cost of implementation41,000 Recommendations with significant savings Savings (£ per year) Invasive treatments– 52,000 Oral NSAIDS-5,000 Estimated saving of implementation– 57,000 Total net saving of implementing the guideline-16,000

13. Discussion Which core recommendations present the most challenges for local practice? Offering topical NSAIDs before oral dosage forms is likely to be a change to established clinical patterns. What needs to happen and by when? What changes do we need to make in relation to surgical services and the way we commission them? What are the next steps to be considered in implementing the core treatments locally?

14. Find out more Visit www.nice.org.uk/CG059 for:www.nice.org.uk/CG059 Other guideline formats Costing report and template Audit support