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Osteoarthritis (OA) can have a debilitating effect on lives. Sufferers can find themselves living with chronic pain and coping with restricted movement, stiffness and fatigue. The condition can force people to give up work and leisure activities, leading them to lose contact with family, friends and colleagues and triggering low mood and depression.
“Osteoarthritis has a considerable impact on quality of life,” says Dr John Dickson, who is a GP and community rheumatologist as well as a clinical adviser to the NICE guideline development group. “In severe cases, the pain may be debilitating and osteoarthritis symptoms can affect confidence, self-esteem, independence and participation in much loved hobbies and interests. Recognition of these impacts and effective support and management of the condition are therefore imperative. This is especially so when there are additional co-morbidities such as diabetes and obesity.”
Osteoarthritis is often seen as a natural part of ageing, which is why people don’t always seek help straightaway. The condition affects most people as they get older but younger people can also be affected.
“Osteoarthritis becomes commoner after the age of 45 years,” says Dr Dickson. “Certain groups of people – such as high grade sportspeople who may have previous injuries or fractures – may experience the condition much younger. Another group are motorcyclists who have a higher incidence of accidents.”
Osteoarthritis symptoms may come on gradually over several years. The earlier symptoms of joint pain and stiffness may be ignored or attributed to strains and sprains, and some people may not consult their GP until their osteoarthritis is more advanced. According to Dr Christine Haseler, Arthritis Care’s medical expert, plenty can be done in the earlier stages, in terms of analgesics, lifestyle measures and physiotherapy, especially for younger people.
Although osteoarthritis can’t be cured, it doesn’t necessarily get worse over time. Many people with the condition find that a combination of OTC analgesics and self-help measures can keep their symptoms at bay.
A recent report, ‘Over-the-counter options for osteoarthritis joint pain: reviewing the latest evidence’,1 assessed the role of OTC medicines and nutritional supplements in the self-management of osteoarthritis. Non-pharmacological approaches, such as weight loss and physical activity, are considered core interventions, the report says, with prescription and non-prescription medications added when required.
Dr Dickson, a contributor to the report, says a multi-disciplinary approach is important, with GPs, pharmacists, physiotherapists and occupational therapists all having key roles in the management of the condition.
If OTC measures fail to work, GPs can prescribe stronger analgesics or suggest corticosteroid injections directly into the affected joint(s). They may refer patients to an orthopaedic surgeon if they have severe arthritis affecting weight-bearing joints (e.g. the knees or hips). Dr Haseler suggests patients opt for a conservative approach where possible, including pharmacy advice and products, before resorting to secondary care.
“Seventy per cent of people don’t get any worse over a five-year period and their symptoms can usually be managed in a primary care setting,” she says. “GPs and other healthcare professionals such as pharmacists can advise on suitable analgesics, exercise and weight loss approaches. The main aim is to find something that gets people mobile again so they are confident to be more physically active, which will help their symptoms and general health in the long-term.”
Analgesics are not the mainstay treatment for osteoarthritis but still have an important management role. “Analgesics can help with pain and enable people to be more mobile and physically active,” says Dr Haseler. “Osteoarthritis is a fluctuating condition and analgesics shouldn’t be viewed as a long-term solution as people don’t have to take them forever. They need to discover what works for them and titrate the analgesic doses up and down according to their symptom severity.”
The current NICE guideline on the pharmacological management of osteoarthritis (due to be updated in September) recommends both paracetamol and topical non-steroidal anti-inflammatory drugs (NSAIDs) as first-line treatments, with oral NSAIDs and opioids as second-line choices. NICE guidelines on the care and management of osteoarthritis, published in February 2014, recommend topical NSAIDs and topical capsaicin, especially for hand and knee osteoarthritis. Local heat or cold may help, but topical rubefacients shouldn’t be recommended.
In March 2016, a review in The Lancet suggested paracetamol has a very low chance of improving osteoarthritic pain and therefore should no longer be the first choice of analgesic. NSAIDs, such as ibuprofen and diclofenac, are more effective at reducing pain, although they have more long-term side-effects. “Conflicting reports have caused patient confusion,” says Dr Haseler. “Some patients worry about how to manage their pain effectively and safely. If customers are taking NSAIDs regularly, it is essential that they are prescribed omeprazole protection as well to reduce the risk of side-effects.”
Dr Martin Johnson, clinical lead for pain at the Royal College of General Practitioners, says the risks and benefits of all analgesics should be considered when deciding which analgesic is the most suitable. “Recent studies suggest long-term and high-dose paracetamol consumption may be associated with cardiovascular, renal and gastrointestinal effects, while only providing minimal long-term pain relief in osteoarthritis,” he says.
“NSAIDs also have been associated with a spectrum of adverse events, particularly risks of peptic ulcers and gastric bleeds. Common opioid side-effects include drowsiness, nausea, constipation and dependence concerns. There are a number of scenarios under which these medications should be used with caution, so awareness of the evidence base, risks and appropriate usage for each is essential.
Osteoarthritis affects around 80 per cent of people over 50 in the UK
Each year, 2 million adults visit their GP because of the condition
Research suggests that 81 per cent of people with OA are in constant pain or limited in performing everyday tasks
The NICE guidelines published in February 2014 advise that exercise is a core treatment for everyone with osteoarthritis, whatever their age, pain severity or disability. “Pacing, suitable footwear and weight loss should also be considered in tailored, individualised self-management plans,” says Dr Johnson.
“Planning ahead is helpful for pacing, to decide which the most important tasks are that need to be completed first, and how they can be broken down – rather than rushing and over-exerting themselves to achieve everything all in one go. Fatigue is a common osteoarthritis symptom, so breaking up activity with regular, planned rest periods is beneficial.”
Too much exercise or strenuous or high-impact exercise may exacerbate joint issues, so these should be avoided. “When it comes to exercise, generally people should be looking at low impact exercise, such as walking, swimming and cycling,” says Lynda Attias from Arthritis Care’s helpline team. “A referral to a physiotherapist can be very helpful, as he/she will draw up a structured programme of exercises for the joints in need. This will help in keeping the joints and muscles moving, keeping people mobile and helping to ease their pain.”
Dr Haseler says it is a question of getting the balance right. Some people are frightened of moving too much in case they trigger more wear and tear, but inactivity causes joints to stiffen, creating a vicious circle.
“People need to be advised to use a commonsense approach and explore all options,” she says. “Walking is the best form of exercise, but it is important that people are walking in the right way to make sure they don’t cause further damage. Walking with poles, for example, takes the strain off their joints, so this is something they should consider. Walking on soft surfaces is also a good idea as is wearing appropriate footwear. Osteoarthritis patients could also speak to a trained yoga teacher to improve their flexibility.”
Losing weight should be encouraged, as this reduces excessive mechanical loading of the joints. “Eating a balanced diet and maintaining a healthy weight can have a massive impact for everyone with regards to their health and wellbeing,” says Lynda Attias. “A healthy lifestyle is really important when you have arthritis as it will help sufferers manage their condition and hopefully stop it getting any worse.
“Our publications on healthy eating and exercise give comprehensive information and can be a really helpful read. To order free helpline posters and booklets, such as ‘Living with osteoarthritis’, ‘Healthy eating and arthritis’ and ‘Exercise and arthritis’, call 020 7380 6540 or email publicationorders@ arthritiscare.org.uk.”
According to Arthritis Research UK, around 60 per cent of people with arthritis and musculoskeletal conditions have tried complementary and alternative medicines to ease their symptoms. Dr Johnson says dietary supplements prove very popular with arthritis sufferers, with a number of options available.
“There is good evidence for a particular extract of rosehip, a galactolipid called GOPO, which has natural anti-inflammatory properties,” he says. Glucosamine and chondroitin are popular nutritional supplements and, anecdotally, some patients do see benefit, but NICE recommends against prescribing these supplements due to mixed clinical evidence.
Fish oil (omega 3) supplements are also very popular as they have strong anti-inflammatory properties. Good evidence exists for their use in rheumatoid arthritis but there is limited data for their benefit in osteoarthritis. Dr Haseler stresses that, while a particular dietary supplement may help one customer with osteoarthritis, it may not be effective for the next customer.
“It is important to take an individualised approach, rather than a prescriptive one, as everyone responds differently,” she says. “There is evidence for and against glucosamine and chondroitin, for example. Pharmacists should make sure that customers are choosing products that are an appropriate cost for them, are helping and do no harm.”
Chronic pain can be very isolating so it is important that arthritis patients realise they are not alone. Referral to a specialist pain clinic, where the focus is on effective pain relief, alongside physiotherapy, psychology and occupational therapy, may be possible.
Pain management programmes are also available in some parts of the country to teach ways of dealing with chronic pain, enabling patients to improve their quality of life. With these programmes, pain relief is not the primary goal – instead, they may focus on psychological therapies, practical approaches and complementary therapies such as acupuncture. Psychologically-based programmes are often taught in groups, enabling patients to meet other people with arthritis.
“Well run pain management programmes can be very effective for those living with chronic pain,” says Dr Johnson. “They should take into account both the physical and psychological implications of living with chronic pain, and consider the individual holistically to promote behaviour change and wellbeing.”
1. Over-the-counter options for osteoarthritis joint pain: reviewing the latest evidence (available to download from patient.info/jointpainhub/hcp)