1. Implementing NICE guidance
Osteoarthritis
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on ‘Osteoarthritis: the care and management of osteoarthritis in adults’. This guideline has been written for professionals caring for adults with a working diagnosis of osteoarthritis in the following settings:
primary and secondary care in the NHS
following referral to surgical or specialist care services
the interface with social services.
This guideline replaces the osteoarthritis aspects only of ‘Guidance on the use of cyclo-oxgenase (Cox) II selective inhibitors, celecoxib, rofecoxib, meloxicam and etodolac for osteoarthritis and rheumatoid arthritis’. NICE technology appraisal guidance 27. Available from
The guidance is available in a number of formats. You can download these from the NICE website or order printed copies of the quick reference guide by calling NICE publications on or sending an to Quote reference number N1459. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it.
You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters to help highlight key points to raise in your presentation and to provide supplementary information to the slides. Where necessary, the recommendation will be given in full. Please feel free to adapt, amend or remove these notes as you see necessary.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
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
NOTES FOR PRESENTERS:
Key issues to raise:
In this presentation we will start by providing some background information on osteoarthritis and explain why the guideline is important.
The NICE guideline contains six key priorities for implementation, which you can find in your quick reference guide. The key priorities for implementation cover the following areas:
exercise and manual therapy
invasive treatments for knee osteoarthritis
pharmacological management of osteoarthritis
topical treatments
non-steroidal anti-inflammatory drugs (NSAIDs) and highly selective COX-2 inhibitors
referral criteria for surgery.
Additional information:
Costs and savings that are likely to be incurred in implementing the guideline are summarised, followed by a suggested list of questions to help prompt discussion. Information on how to find out more about the support provided by NICE is given at the end of this presentation.

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.
NOTES FOR PRESENTERS:
Key points to raise:
The advice in the NICE guideline covers the treatment, advice and support that people who have osteoarthritis should be offered by their healthcare professional and when being referred to specialist care. This includes: diagnosis, education, exercise and physiotherapy, medicines, alternative therapies and surgery.
The guideline does not specifically look at the care and management of related conditions (for example, rheumatoid arthritis and joint pain).
Additional information:
Osteoarthritis is the most common form of arthritis in the UK. In the joints of a person with osteoarthritis, the tissue (also known as cartilage) covering the bones becomes damaged and worn, which causes pain, stiffness and limited movement in the affected areas. Occasionally, joints can swell up and become inflamed. The severity of symptoms varies greatly, with pain and symptoms often flaring up and settling back down again.
Osteoarthritis is a metabolically active repair process that takes place in all joint tissues and involves localised loss of cartilage and remodelling of adjacent bone. A variety of joint traumas may trigger the need to repair. Osteoarthritis is a slow but efficient repair process that often compensates for the initial trauma, resulting in a structurally altered but symptom-free joint. In some people, either because of overwhelming trauma or compromised repair potential, the process cannot compensate, resulting in continuing tissue damage and eventual presentation with symptomatic osteoarthritis or ‘joint failure’. This explains the extreme variability in clinical presentation and outcome that can be observed between people and also at different joints in the same person.
Osteoarthritis can occur in young people as well as older people. The hips, knees, hands and the lower part of the spine are most commonly affected. Shoulders, elbows, wrists and the feet can also be affected, but this is less common. Osteoarthritis may occur in more than one joint at any given time.
Many people consider that osteoarthritis is a normal part of ageing, always gets worse and cannot be treated. However, osteoarthritis does not always worsen with age and there are treatments available and lifestyle changes that can help ease the pain and symptoms.

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.
NOTES FOR PRESENTERS:
Key points to raise:
This is not a key priority for implementation, however, it is important to take a holistic approach to the assessment and management of osteoarthritis. Figure 1, which can be found in the NICE guidance at should be used as an aid to prompt questions that should be asked as part of the holistic assessment of a person with osteoarthritis.
Additional information:
People with symptomatic osteoarthritis should have periodic review tailored to their individual needs.
Healthcare professionals should formulate a management plan in partnership with the person with osteoarthritis.
Comorbidities that compound the effect of osteoarthritis should be taken into consideration in the management plan.
The risks and benefits of treatment options, taking into account comorbidities, should be communicated to the patient in ways that can be understood.

5. Targeting treatment NOTES FOR PRESENTERS: Key points to raise:
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
NOTES FOR PRESENTERS:
Key points to raise:
This figure is ‘Figure 2 Targeting treatment: a summary of the treatments recommended in sections 1.2 to 1.5’ and is taken from the NICE guideline.
Starting at the centre and working outward, the treatments are arranged in the order in which they should be considered for people with osteoarthritis, given that individual needs, risk factors and preferences will modulate this approach.
Additional information:
In accordance with the recommendations in the guideline, there are three core treatments that should be considered for every person with osteoarthritis – these are given in the central circle. Some of these may not be relevant, depending on the person.
Where further treatment is required, consideration should be given to the second ring, which contains relatively safe pharmaceutical options. Again, these should be considered in light of the person’s individual needs and preferences.
A third outer circle gives adjunctive treatments. These treatments all meet at least one of the following criteria: less well-proven efficacy, less symptom relief or increased risk to the patient. The outer circle is further divided into four groups: pharmaceutical options, self-management techniques, surgery and other non-pharmaceutical treatments.
This figure gives an overview of when to use particular treatments. In the next six slides we will present the key priorities for implementation taken from the NICE guideline, which are highlighted in the quick reference guide.

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.
NOTES FOR PRESENTERS:
Key points to raise:
This is a key priority for implementation.
Healthcare professionals should offer all people with clinically symptomatic osteoarthritis advice on the following core treatments.
Access to appropriate information (see section in the NICE guideline).
Activity and exercise (see section in the NICE guideline).
Interventions to achieve weight loss if person is overweight or obese (see section in the NICE guideline and ‘Obesity’ [NICE clinical guideline 43]).
Some of these core treatments may not be relevant, depending on the person.
It has not been specified whether exercise should be provided by the NHS or whether the healthcare professional should provide advice and encouragement to the patient to obtain and carry out the intervention themselves.
Exercise has been found to be beneficial but the clinician needs to make a judgement in each case on how to effectively ensure patient participation. This will depend upon the patient’s individual needs, circumstances, self-motivation and the availability of local facilities.
Recommendation in full: as on slide (see also in the NICE guideline).

7. Adjunct to core therapy: paracetamol
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.
NOTES FOR PRESENTERS:
Key points to raise:
This is a key priority for implementation.
Where further treatment is required, consideration should be given to relatively safe pharmaceutical options. Again, these should be considered in light of the person’s individual needs and preferences. These adjunctive treatments all meet at least one of the following criteria: less well-proven efficacy, less symptom relief or increased risk to the patient. In the guideline they are further divided into four groups: pharmaceutical options, self-management techniques, surgery and other non-pharmaceutical treatments.
Additional information:
Although NSAIDs and COX-2 inhibitors may be regarded as a single drug class of ‘NSAIDs’, these recommendations continue to use the two terms for clarity, and because of the differences in side-effect profile.
The guideline recommendations are based on up-to-date evidence on efficacy and adverse events, current costs and an expanded health-economic analysis of cost effectiveness. This has led to an increased role for COX-2 inhibitors, an increased awareness of all potential adverse events (gastrointestinal, liver and cardio-renal) and a recommendation to co-prescribe a proton pump inhibitor (PPI).
Recommendation in full: as on slide and see in the NICE guideline.

8. Adjunct to core therapy: topical treatments
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.
NOTES FOR PRESENTERS:
Key points to raise:
This is a key priority for implementation.
Topical capsaicin should be considered as an adjunct to core treatment for knee or hand osteoarthritis.
Rubefacients are not recommended for the treatment of osteoarthritis.
Additional information:
Figure 2 in the NICE guideline (and on slide 5) gives more information on targeting treatment and is a summary of the treatments recommended in the guideline.
Recommendation in full: as on slide and see in the NICE guideline.

9. Adjunct to core therapy: Oral NSAID/Cox-2 inhibitors
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.
NOTES FOR PRESENTERS:
Key points to raise:
This is a key priority for implementation.
Again, these should be considered in light of the person’s individual needs and preferences.
Additional information:
If a person with osteoarthritis needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2 inhibitor (with a PPI) if pain relief is ineffective or insufficient.
Where paracetamol or topical NSAIDs are ineffective for pain relief for people with osteoarthritis, then substitution with an oral NSAID/COX-2 inhibitor should be considered.
Oral NSAIDs/COX-2 inhibitors should be used at the lowest effective dose for the shortest possible period of time.
All oral NSAIDs/COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal, liver and cardio-renal toxicity; therefore, when choosing the agent and dose, healthcare professionals should take into account individual patient risk factors, including age. When prescribing these drugs, consideration should be given to appropriate assessment and/or ongoing monitoring of these risk factors.
Recommendation in full: as on slide and see in the NICE guideline.

10. Adjunct to core therapy: referral criteria for surgery
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.
NOTES FOR PRESENTERS:
Key points to raise:
This is a key priority for implementation.
Clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core (non-surgical) treatment options (see recommendation and figure 2 in the NICE guideline).
Joint symptoms are pain, stiffness and reduced function.
Additional information:
Patient-specific factors (including age, gender, smoking, obesity and comorbidities) should not be barriers to referral for joint replacement surgery.
Decisions on referral thresholds should be based on discussions between patient representatives, referring clinicians and surgeons, rather than using current scoring tools for prioritisation.
Recommendation in full: as on slide and see in the NICE guideline.

11. Adjunct to core therapy: invasive treatments for knee osteoarthritis
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).
NOTES FOR PRESENTERS:
Key points to raise:
This is a key priority for implementation.
This recommendation is a refinement of the indication in ‘Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis’. NICE interventional procedure guidance 230. Available from
Additional information:
This guideline has reviewed the clinical and cost-effectiveness evidence, which has led to this more specific recommendation on the indication for which arthroscopic lavage and debridement is judged to be clinically and cost effective.
Related NICE guidance:
Single mini-incision hip replacement. NICE interventional procedure guidance 152 (2006). Available from
Mini-incision surgery for total knee replacement. NICE interventional procedure guidance 117 (2005). Available from
Minimally invasive two-incision surgery for total hip replacement. NICE interventional procedure guidance 112 (2005). Available from
Artificial trapeziometacarpal joint replacement for end-stage osteoarthritis. NICE interventional procedure guidance 111 (2005). Available from
Recommendation in full: as on slide (see also in the NICE guideline).

12. Costs and savings per 100,000 population
Recommendations with significant costs
Costs
(£ per year)
Topical NSAIDs
18,000
Proton pump inhibitors
23,000
Estimated cost of implementation
41,000
Recommendations with significant savings
Savings
Invasive treatments
– 52,000
Oral NSAIDS
-5,000
Estimated saving of implementation
– 57,000
Total net saving of implementing the guideline
-16,000
NOTES FOR PRESENTERS:
Key points to raise:
The estimated net saving per 100,000 population associated with implementing this guideline is £16,000, as summarised in the table.
The information on this slide has been extracted from the NICE costing report, which has been provided by NICE to support implementation of this guidance. It was developed after careful consideration of the available data and by working closely with the guideline developers and other people in the NHS. It is not NICE guidance. Assumptions used in this report are based on assessment of the national average and it is recognised that local practice or circumstances may differ from this. The costs published in this report are estimates only and are not to be taken as the Institute's view of desirable, or maximum or minimum figures.
Additional information:
NICE has also provided a costing template to help calculate the local costs associated with implementing this guideline.
It is recognised that implementation of the recommendations may take place over a number of years.
In addition, compliance with NICE guidance is one of the criteria indicating good risk reduction strategies, and in combination with meeting other criteria could lead to a discount on contributions to the NHS Litigation Authority schemes, including the clinical negligence scheme for trusts (CNST).
For further information please refer to the costing template and costing report for this guidance on the NICE website.

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?
NOTES FOR PRESENTERS:
Key points to raise:
These questions are suggestions that we have developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

14. Find out more Visit www.nice.org.uk/CG059 for: Other guideline formats
Costing report and template
Audit support
NOTES FOR PRESENTERS:
Key points to raise:
The guideline is available in a number formats:
The quick reference guide – which summarises the guidance.
The NICE guideline – which includes all of the recommendations in full.
The full guideline – which includes all the evidence and rationale.
‘Understanding NICE guidance’ – a version for patients and carers.
Additional information:
You can download these from the NICE website or order printed copies of the quick reference guide and ‘Understanding NICE guidance’ by calling NICE publications on or by sending an to Quote reference number N1459 (quick reference guide) and N1460 (‘Understanding NICE guidance’). You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it.
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved. These were published at the point of publication of the guideline.
The following tools will be published approximately 10 weeks after publication of the guideline, in May 2008:
Audit support − assists NHS trusts to determine how well they meet NICE recommendations.