Transcript Using this template - British Osteopathic Association

Osteoarthritis
Implementing NICE guidance
2008
NICE clinical guideline 59
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
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.
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.
Targeting treatment
oral NSAIDs
including COX-2
inhibitors
opioids
capsaicin
intra-articular
corticosteroid
injections
paracetamol
supports
and braces
topical
NSAIDs
education, advice,
information access
shock-absorbing
shoes or insoles
strengthening exercise
aerobic fitness training
assistive
devices
weight loss if
overweight/obese
TENS
manual therapy
(manipulation and
stretching)
local heat and
cold
joint
arthroplasty
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.
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 antiinflammatory drugs (NSAIDs) should be considered
ahead of oral NSAIDs, cyclo-oxygenase 2 (COX-2)
inhibitors or opioids.
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.
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.
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.
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).
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
Invasive treatments
Oral NSAIDS
Savings
(£ per year)
– 52,000
-5,000
Estimated saving of implementation
– 57,000
Total net saving of implementing the guideline
-16,000
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?
Find out more
Visit www.nice.org.uk/CG059 for:
• Other guideline formats
• Costing report and template
• Audit support