Treatment of Osteoarthritis Pain in General Practice
 

Osteoarthritis (OA) is the most common form of arthritis and a leading cause of pain and disability worldwide.1 OA presents as a clinical syndrome which affects joints, causing pain, limiting activity/mobility and reducing quality of life. Ireland has over 450,000 osteoarthritis sufferers, according to Arthritis Ireland.6

 

An ageing population and rising obesity rates are contributing to an increase in this debilitating disease, and the number of adults diagnosed with osteoarthritis in Ireland expected to rise by 29% by 2020.2 Women are also more likely to develop osteoarthritis than men. A recent Irish study found that the overall prevalence rate in an over-50 population is 17.3% for women and 9.4% for men.3

 

Specific causes of osteoarthritis are not well understood. While traditionally thought to be due to excessive wear and tear, the condition is now believed to be much more complex with a variety of causes contributing to the condition, including metabolic factors, genetic factors, trauma or injury, bone and joint malfunctions or a combination of these factors.4 Osteoarthritis can occur in any synovial joint, but in Europeans it is most common in the hands, knees, and hips.4,5

 

There is no cure for osteoarthritis. Current therapeutic strategies are primarily aimed at reducing pain and improving joint function.1,4 The diagnosis of osteoarthritis is usually made clinically, and can be confirmed by radiography if required. Osteoarthritis often presents as joint pain that is made worse by activity and relieved by rest. However, in more advanced disease it is painful at rest and at night.5

 

The treatment goals for osteoarthritis are to control pain and reduce stiffness and functional limitation. This may be achieved primarily through the combination of non-pharmacological and pharmacological treatments.

 

Non-pharmacological treatment1

Exercise: People with osteoarthritis should be recommended to exercise. Exercises that encourage muscle strengthening, stretching and aerobic fitness should be encouraged.

 

Weight loss: Obese/overweight people should be offered an intervention to achieve weight loss.

 

Electrotherapy: The use of transcutaneous electrical nerve stimulation (TENS) as an addition to mainstay treatments for pain relief should also be considered.

 

Pharmacological treatment1

The National Institute for Health and Care Excellence (NICE) recommend that ‘paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be offered for pain relief, ahead of oral NSAIDs, cyclo-oxygenase 2 (COX-2) inhibitors or opioids’.1

 

However, if these are insufficient for pain relief then the addition of opioid analgesics should be considered, taking into consideration the risks and benefits, particularly in older people.1

 

Codeine ‘should be considered as the first line opioid therapy if stronger forms of analgesia are required,’ according to the Department of Social Protection’s osteoarthritis policy document.4 It adds that codeine can be prescribed either alone, or in preparations containing paracetamol. ‘Stronger forms of opioid therapy such as fentanyl, buprenorphine patches or morphine should only be prescribed on specialist advice,’ it states.4

 

The NICE guidelines advise that ‘intra-articular corticosteroid injections should be considered as an adjunct to the core treatments [of weight loss and exercise] for the relief of moderate to severe pain in people with osteoarthritis’.1

 

Healthcare professionals may decide to refer patients with osteoarthritis for joint surgery if they continue to “experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life” despite treatment with analgesics and lifestyle modifications.1 Joint surgery should be considered after the core treatments for osteoarthritis have been offered and the risks and benefits of surgery (and not having surgery) have been discussed with the patient.1

 

The NICE guidelines also highlight the importance of regular patient reviews to monitor symptoms and treatment effectiveness, any impact on quality of life and mobility, and to support for self-management.

 

References:

  1. Osteoarthritis: care and management. Clinical guideline [CG177]. NICE 2014. Available online nice.org.uk/guidance/cg177. Accessed 12/4/2017
  2. Institute of Public Health in Ireland. Musculoskeletal Conditions Briefing: Technical Documentation. 2012; Dublin: Institute of Public Health in Ireland.
  3. French HP, et al. Prevalence and burden of osteoarthritis amongst older people in Ireland: findings from The Irish LongituDinal Study on Ageing (TILDA). Eur J Public Health. 2016; 26(1): 192-8
  4. Department of Social and Family Affairs. Medical Assessment Protocol 15: Osteoarthritis. 2014.
  5. Hunter DJ, Felson DT. Clinical review: Osteoarthritis. BMJ 2006; 332: 639- 42.
  6. Campos. A. Arthritis Sufferers in fight for "wonder gel". www.irishmirror.ie. Accessed 26/4/2017



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