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Topical NSAIDs first line in osteoarthritis, says NICE

By Nigel Praities

NICE have overturned traditional advice on osteoarthritis and recommended wider use of topical NSAIDs and proton pump inhibitors, in new guidance.

The guidelines recommend topical NSAIDs as first-line pharmacotherapy, along with paracetamol. If these treatments prove insufficient, oral NSAIDs or COX-2 inhibitors (other than etoricoxib 60mg) are recommended.

Following reports about the gastric safety of these treatments, NICE recommend the prescription of the cheapest PPI for all patients, whether on traditional oral NSAIDs or COX-2s.

Dr Graham Archard, a GP in Dorset and a member of the NICE guideline committee, said he predicted GPs would be surprised by the expansion of gastroprotection recommended for patients.

‘Before this guidance we would never have considered giving PPIs for a healthy young male on NSAIDs or COX-2s. But it is good medical practice and is cost-effective,' he said.

Although Dr Archard admitted there would be an increase in prescribing costs, but he argued the PPI guidance would prevent hospital admissions and expensive procedures.

Dr Christian Mallen, GP in Newcastle-under Lyne and musculoskeletal research fellow at Keele University, said NICE advice was ‘quite cautious' and PPI prescription should be based on an individual's risk factors and the duration of NSAID treatment.

‘If you are just going to be using it for a short duration of time, if they have an acute exacerbation of their osteoarthritis, then it might be completely appropriate not to use a PPI for gastroprotection,' he said.

NICE's endorsement of topical NSAIDs as first-line treatment follows UK research published in the BMJ last year that showed that they were as effective as oral NSAIDs for treating knee pain and were preferred by patients in primary care.

Dr Louise Warburton, a musculoskeletal GPSI who works in a hospital rheumatology department in Shropshire, said this recommendation vindicated what GPs had known anecdotally for years.

‘We have always been told by PCT advisors that they don't work, but they actually do,' she said.

Other new recommendations from NICE include exercise as a ‘core treatment' for osteoarthritis along with weight-loss, irrespective of age, pain severity or disability. This was welcomed by Dr Mallen, even though it may be ‘counterintuitive' for patients: ‘Exercise in all forms is very beneficial, particularly for pain reduction,' he said.

NICE osteoarthritis guidance at a glance NICE osteoarthritis guidance at a glance

Exercise, weight loss, education and advice are core treatments
Topical NSAIDs and paracetamol should be considered first-line
If pain relief is insufficient, then oral NSAIDs or COX-2s should be prescribed, in conjunction with PPIs
Glucosamine is not recommended for the treatment of osteoarthritis
Age, obesity, gender, smoking or concomitant illness should not dissuade GPs from referring patients for specialist treatment

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