Osteoarthritis in GP: Nice update, October 2022

This is an updated guideline on osteoarthritis from Nice. The last update was in 2014. This was published in Oct 22. I shall outline what is new and what has changed in the management of osteoarthritis (OA) and then do a more in-depth summary. I have included some of the evidence that they have based their decisions on, which I think is worth a look at and may well change the advice that you give to patients.

What is new in ‘Osteoarthritis in over 16s: diagnosis and management’?

The following bits of guidance were new for 2022:

• There is a section on advice that we should give to patients. Most of this is what we would have been advising patients anyway.
• Exercise is rebranded as ‘therapeutic exercise’. Although I thought this was a bit irritating at first, I can see how it will avoid those ‘but I already exercise doctor’ moments.
• Footwear. There is no recommendation on footwear in this iteration of the guideline.
• TENS machines and the use of hot and cold packs have gone out of favour.
• Manipulation should only be advised alongside therapeutic exercise.
• Topical NSAIDs are the first line treatment for knee OA. They can be considered for other forms of OA.
• Topical capsaicin doesn’t get as far as the main guideline – there is evidence that it is effective for knee OA (but not other forms of OA), but it is not as cost-effective as topical NSAIDs. I recommend reading the section on this below though before purging this from your list of useful options…
• Oral NSAIDs are second line therapy.
• Paracetamol is not effective and shouldn’t routinely be used.
• Strong opioids shouldn’t be used. Their harms outweigh the benefits.
• Arthroscopy. No form of arthroscopy is advised.
• Joint replacement. Referral for joint replacement should not be restricted because of a patient’s BMI. There is no difference in mortality across most different BMI groups and there is still good evidence of efficacy.
• Follow-up can be patient-initiated for most patients.

How should GPs diagnose OA?

There is no need for further investigation if:

• 45 and over AND
  • Activity related joint pain AND
    • No morning stiffness, or stiffness that lasts < 30 mins