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Independents' Day

Need to know - osteoarthritis

A team of experts led by Professor Elaine Hay and GP Dr Mark Porcheret answer GP Dr Pam Brown’s questions on exercise, NSAIDs, joint injections and cox-2s

A team of experts led by Professor Elaine Hay and GP Dr Mark Porcheret answer GP Dr Pam Brown's questions on exercise, NSAIDs, joint injections and cox-2s

1. Along with weight reduction, what lifestyle measures should we recommend where OA affects weight-bearing joints?

41182464The single most important recommendation for all patients with hip and knee OA is to emphasise the importance of both weight-bearing and non-weight-bearing exercise. The overall aim should be to support patients to translate exercise regimes into sustainable lifestyle changes – for example, by incorporating walking, dancing or swimming into their weekly routine. The safety of exercise should be emphasised, and myths such as ‘hurt equals harm' dispelled. The importance of wearing appropriate footwear – trainer-type shoes are ideal – should be emphasised.

Depression is common in patients with OA. It is associated with increased pain and disability and often goes unrecognised. Recognising and treating depression is a key role for the primary healthcare team.

2. Which exercise regimens are appropriate for patients with OA, and what is the role of physiotherapy?

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. Water-based and land-based regimens are both recommended, and should be tailored to the patient's individual needs, circumstances, self-motivation and the availability of local facilities.

The new NICE guideline does not specify whether exercise should be provided by the NHS or whether the clinician should provide advice and encouragement to the patient to arrange exercise for themselves. However, the vast majority of studies of beneficial exercise are based on instruction by a health professional, often a physiotherapist.

Patients with symptomatic hip and knee OA may therefore benefit from referral to a physiotherapist for evaluation and instruction in appropriate exercises to reduce pain and improve functional capacity. Onward referral should also enable access to a

range of other recommended non-pharmacological options, including assisted devices, braces and support, thermotherapy, footwear and insoles, and instruction on the use of TENS.

3. How should we use NSAIDs, both topically and orally?

In a change to current clinical practice, the NICE guideline published in February recommends the use of a topical NSAID before considering oral NSAIDs or cox-2 inhibitors, particularly for knee or hand OA.

Recent research has shown that topical NSAIDs are as effective for pain relief as oral NSAIDs, with fewer adverse reactions. Furthermore, patients with mild or moderate symptoms tend to prefer topical to systemic treatment.

The NICE OA guideline model of care (see diagram below) suggests all patients should receive ‘core treatments', consisting of education and advice, exercise and aerobic fitness training, and weight loss if obese. Paracetamol and topical NSAIDs are then added in before considering other ‘adjunctive treatments', including systemic NSAIDs and opioid analgesia. The use of oral NSAIDs is covered above.

4, What is the role of other topical agents, such as rubefacients and capsaicin?

Rubs of various kinds are an age-old remedy for painful joints – I can still smell the white liniment that one of my elderly patients rubbed into his arthritic hips every morning. But apart from topical NSAIDs, the NICE guideline only recommends the use of capsaicin, whose active ingredient is an extract of chillies. It works by depleting substance P in local nerve endings, which is thought to play a role in the transmission of painful stimuli.

It can burn at first but after several days' use can provide a useful numbing effect.

It does not work for everyone, and for some the initial burning is a barrier to use, but many patients swear by it. It can be particularly effective for small joints of the hand, especially that very common site for OA: the base of the thumb. It has also been shown in trials to be effective for knee OA.

It is worth a try in patients needing additional pain relief to simple analgesia.

5. There is now much conflicting data about the safety of cox-2 inhibitors. Which one has the best safety profile and which patient should receive these rather than conventional NSAIDs and gastroprotection?

41182462This is an area that is covered in great detail in the NICE OA guideline, as one of its remits was to fully review the advice on cox-2 inhibitors given in an earlier technology appraisal. Extensive health-economic modelling was undertaken, which took into account all potential adverse events – gastrointestinal, liver and cardiorenal – to produce a number of recommendations (see box).

So, how do the NICE guidelines help us to answer the question posed?

The message seems to be that all NSAIDs – non-selective and cox-2 inhibitors – should be considered as a single group with varying degrees of cox-2 selectivity and, to quote NICE, ‘different (though not always consequent) side-effect profiles'.

Cox-2 inhibitors should only be considered after first trying paracetamol and topical NSAIDs and it is best not to use them with low dose aspirin.

Cox-2 inhibitors (as well as NSAIDs) should be coprescribed with a PPI – omeprazole 20mg/d was used in the NICE cost-effectiveness model.

In the economic modelling, celecoxib 200mg/d with a PPI was shown to be the most cost-effective option for using an NSAID or cox-2 inhibitor – with etoricoxib 30mg/d as a cost-effective alternative – both for younger adults (age 55) at low GI and CV risk and older adults (age 65) with a CV risk up to three times the average for their age. However, they are contraindicated (see BNF) in patients with active peptic ulceration, ischaemic heart disease, cerebrovascular disease, peripheral vascular disease and moderate or severe heart failure. Even if they are cost-effective, the risks for the individual need to be explained.

A recent MeReC publication is excellent further reading and gives a detailed review of the cardiovascular and gastrointestinal safety of NSAIDs.

6. What is the evidence that intra-articular hyaluronic acid injections are more effective or provide longer-lasting benefit than steroid injections?

The evidence presented in the NICE guidelines demonstrates that an intra-articular steroid reduces pain in the short term – one to four weeks. The best evidence is for knee OA, but there is some evidence that it is effective in hip and hand OA. It is difficult to predict which patients will respond to treatment, so its use should not be confined to those with an effusion, and it is the degree of uncontrolled pain that should dictate use.

There is no evidence that IA hyaluronan is more effective than IA steroids, but its effect can last up to three months longer. However, it is not recommended for use

in the NHS because of its high cost, and NICE concluded that ‘in all cases, the cost-effectiveness estimate is outside the realms of affordability to the NHS'.

7. Is there evidence for glucosamine and chondroitin in symptom relief and disease modification? What is the optimal dose and should patients use both glucosamine and chondroitin?

Although previous guidelines have recommended the use of glucosamine or chondroitin, NICE does not recommend either for use in the NHS. The guideline group concluded that overall the trial data showed a small benefit over placebo for the symptomatic treatment of OA knee with a single daily dose of 1,500mg of glucosamine sulphate, but that the benefits of structure modification were unknown. However, as the only glucosamine preparation with

an EU product licence is glucosamine hydrochloride, for which there is poor evidence to support its use, glucosamine was not recommended by NICE.

8. But doesn't the decision to grant a POM licence to a pharmaceutical grade glucosamine hydrochloride last year mean patients are entitled to ask us for it on prescription?

In fact, glucosamine sulphate can be prescribed by GPs. Although it does not have a product licence it is not blacklisted, and 64,500 prescriptions were dispensed in 2006 in England, according to Department of Health prescribing statistics.

The NICE guideline group felt people wanting to trial the use of over-the-counter glucosamine should be advised there is only evidence to show it can reduce pain to a mild or moderate degree and to see if it reduces their pain over three months. Whether GPs decide to prescribe it for their patients is going to be up to them to decide, along with their PCT pharmacy advisers and local drug formulary committees.

9. What is the evidence for the inheritance of OA, who is most at risk, and is there a pattern to the joint involvement?

It has long been suspected that there is a significant genetic contribution to OA.

In the 1940s, Stecher demonstrated a threefold increase among the mothers and sisters of patients with Heberden's nodes and more recent epidemiological studies suggest that more than 50% of cases of osteoarthritis have a hereditary element.

Specifically, twin studies have demonstrated a 65% heritability for hand OA, 50% heritability for hip OA and 40% heritability of the knee.

The most common form of OA seen in practice is primary generalised OA, which appears to be related to the human leukocyte antigen (HLA) genotypes

HLA-A1B8 and HLA-B8. OA is also a characteristic feature of some rare inherited syndromes, such as Stickler syndrome – hereditary arthro-ophthalmopathy – and familial calcium pyrophosphate deposition disease (CPDD), for which the genetic component has been well characterised.

The genetic influence but may involve a structural, collagen-related defect, alterations in cartilage or bone metabolism, or a genetic influence on a known risk factor for OA, such as obesity.

10. What can be done to help those with severe OA of the hands, especially the thumbs?

A patient presenting with severe OA of the hands, especially the thumbs, will commonly have bilateral hand problems associated with lower limb problems.

In line with the management of lower limb OA, people should be offered the core treatments of education, advice and information, and strengthening exercises targeted to the hand. Advice on aerobic fitness exercises, such as pool-based exercises, may also be beneficial for the hand. The key pharmacological additions to this core therapy include paracetamol, topical NSAIDs and capsaicin.

Other options to consider include IA steroid injections, TENS for pain relief, local heat or cold therapy, and referral to other services. For example, occupational therapists can advise on joint protection, use of assistive devices and splinting, and physiotherapists can offer manual therapy in addition to exercise.

Referral for surgical assessment should only be offered after core treatments have been used appropriately. Referral for surgery should be made before there is prolonged and established functional limitation and severe pain. For further information refer to the NICE OA and the European League Against Rheumatism (EULAR) guidelines.

11. What criteria should we use to decide when to refer patients for hip or knee arthroplasty, and which scoring systems are practical for use in primary care and where can these be downloaded?

More than 12,000 prosthetic joint replacements are performed every year, accounting for 1% of the country's total healthcare budget. Orthopaedic scoring systems, such as the New Zealand score and the Oxford score, are widely used to assess pain, functional impairment and degree of radiographic damage. These scores were developed to measure population-based changes following surgery rather than to be used as a guide for referral.

The NICE guidelines recommend that all patients should have received the ‘core treatments' prior to any surgical referral. Surgical referral is recommended for people who experience joint symptoms – pain, stiffness, reduced function – that have a substantial impact on their quality of life and are refractory to non-surgical treatments. Decisions on referral should be based on discussions between patients and clinicians rather than the use of scoring systems to prioritise treatment, taking into account relevant comorbidities that may shift the benefit-to-risk ratio for an individual patient.

Professor Elaine Hay is professor of community rheumatology and a consultant rheumatologist

Dr Krysia Dziedzic is ARC senior lecturer in physiotherapy and was a member of the NICE OA guideline group

Dr George Peat is senior lecturer in clinical epidemiology and a physiotherapist

Dr Mark Porcheret is a GP research fellow and a local GP

Dr Christian Mallen is a lecturer in general practice and a local GP

All authors are based at the Primary Care Musculoskeletal Research Centre at Keele University

Competing interests None declared

NICE BOX What I will do now

What I Will Do Now

• I'll continue to help motivate patients with OA to lose weight.
• I'll keep stressing to patients that exercise is beneficial and will not harm their joints.
• I'll use more topical NSAIDs, as I am aware of the evidence base for their safety and efficacy in hand and knee OA, but prescribing them has previously been discouraged because of cost.
• On the rare occasions I prescribe an NSAID for patients with OA, I will now add a PPI. For this reason I am unlikely to use a cox-2 in future.
• I'll continue to refer patients for consideration for arthroplasty when their uncontrolled symptoms impact on their lifestyle and sleep patterns.
• I will discuss the NICE guidance with my prescribing adviser as I still believe patients can benefit from regular use of combination analgesics such as co-codamol which are not recommended by the guidance.
Dr Pam Brown is a GP in Swansea

thp oa Knees Hand 1 Hand 2

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