Following the publication of new draft guidance by NICE on the care and management of osteoarthritis, Dr Fiona Watt breaks down the misconceptions surrounding its impact on patients and healthcare professionals, and why developing effective treatments for the condition is more vital than ever.
8.75 million people live with osteoarthritis in the UK and the condition is the fourth leading cause of years lived with disability worldwide. Osteoarthritis commonly affects joints such as the knee, hip or hand, leading to progressive change and damage in joint tissues, frequently causing joint pain and functional difficulties. It is the leading cause of joint replacement. As an osteoarthritis researcher and someone who treats people with osteoarthritis in the NHS, I awaited the draft updated National Institute for Health & Care Excellence (NICE) guidance on the management of osteoarthritis with some anticipation. This guidance is important because it shapes (and restricts) the way that the NHS approaches advice and treatment, based on scientific evidence.
In many ways, the draft guidance is well balanced, expected and clear. As with the first NICE osteoarthritis guidance published in 2008, it reminds us that good information on the condition, exercise (both joint-specific/muscle strengthening and aerobic) and weight loss need to be front and centre in our management approach.
However, media coverage of NICE’s press release has caused confusion and consternation. A headline in The Times on 28 April, for example, stated: “Stop taking painkillers for arthritis, NHS patients told”. It is important the guidance is read carefully, rather than taking attention-grabbing headlines at face value. It is also important that stakeholders take time to comment on this draft guidance (we can do so until 15 June). Many osteoarthritis researchers and clinicians – myself included – have been reflecting on this commentary, and I feel an overwhelming need to counter the hopelessness expressed on social media in the wake of this misleading coverage.
What was said
There is a lot of evidence to support the effectiveness of exercise and weight loss as treatments for osteoarthritis. NICE is right to emphasise this, because despite being safe and cost-effective, the proven benefits of these approaches are often not communicated clearly, positively or even at all.
The guidance highlights that exercise and weight loss can improve joint pain, function and wellbeing. Other evidence also indicates that these approaches can slow down the progression of the disease. If we could bottle these benefits, everyone would be taking it.
Anecdotally, I still hear about people being offered effective but costly joint replacements without ever having been given advice on joint-specific exercises or weight loss, which is a devastating thing to say given the evidence out there. This is why this message has to be loud and clear, both to clinicians and the public.
But we have a problem: exercising and losing weight are sometimes difficult for any of us to do, not least for people in pain. People find sticking to exercises and weight loss regimes challenging. Also, as with any treatment, sometimes people don’t get better enough, or at all. Joint replacement is an option for some with severe disease, but not everyone. So, “What we do then?” said Twitter, “Don’t tell us we can’t take drugs.”
Drugs and arthritis
It’s important to make clear that the draft guidance does not tell people with osteoarthritis to stop taking their drugs. It does remind clinicians that there is insufficient evidence for some medications.
In the case of paracetamol, people tend to buy this over the counter rather than being prescribed it and nothing stops them from doing this. However, for weak opioids like co-codamol, only short-term use is now recommended. For NICE, there is insufficient evidence of their effectiveness in the long term, but this doesn’t necessarily mean they don’t work. NHS data shows that, post-pandemic, there are over 700,000 people are on waiting lists for trauma & orthopaedics (T&O), which includes hip and knee replacements. Practically speaking, are we really going to withhold long term pain relief from these people with severe joint pain because of a lack of evidence? These guidelines are perhaps not written with such situations in mind.
What isn’t there?
Along with fewer recommended drugs, other treatment approaches such as orthotics (e.g. hand splints) are not included in the guidance. Again, trials cannot agree they are effective, or how they might work. In my experience, one of the issues is that people don’t wear them 24/7, nor should they need to. However, they remain a source of comfort and support for many. Whilst orthotics have a cost which needs to be justified, their absence in the guidance is an example of a diminishing of choice for people. Offering fewer and fewer treatment options beyond the recommended lifestyle changes can give the impression that this condition is unimportant, not worth investment, or even the fault of the individual, because they are “not exercising enough” or “overweight”. Is that really what we are aiming for?
What more can we do?
NICE also highlights the research still needed to fill in knowledge gaps. The list is stark reading for many of us. Some questions are ones we should already know the answer to: “What is the evidence for the cost-effectiveness of long-term, low-dose weak opiates?”. There are also some examples of research that some might feel are common sense, for example, how shoe wear considerations might help people with lower limb arthritis.
There are also some surprises, including the range of unproven therapies included as research questions. Some evidence around stem cell therapy or shock wave therapy in osteoarthritis is available, but not enough, particularly on their safety and use in large trials with appropriate comparators.
What is not highlighted in the draft guidance – perhaps because it is not NICE’s job to do so – is that we need research that discovers new, more effective treatments than the ones they have reviewed.
New treatments for osteoarthritis
Over the last 20 years, we have convincingly shown that osteoarthritis is an active cellular process that, in animal models, can be slowed or reversed. Osteoarthritis in a joint is not just a car tyre wearing out – it is not inevitable and does not always get worse. Disease modification (aiming to prevent, slow or stop the disease) is not mentioned once in the guidance. However, we can do this for other forms of arthritis with drugs.
Internationally, there are ongoing efforts to find new effective drug treatments for osteoarthritis that either target pain in new ways, slow the disease down or both. The guidance does not mention the fate of a new class of drugs which block the substance nerve growth factor, produced at the site of pain and a cause of pain generation, whose development has progressed substantially but not to licensing in recent years.
The guidance also does not mention the long list of drugs in advanced stage clinical trials, some of which appear to cause regeneration of the cartilage. It’s been difficult to get to this point, but we are still going. There should be hope, not hopelessness.
There are still challenges ahead. In terms of effective treatments, one size may not fit all. As a research community, we are grappling with how we might define subgroups of people where a drug works, rather than our previous approach of trying to show it works in everyone.
The importance of searching for more
NICE is there to tell us what the current situation is, and what we can do to make things better now, which is so important for an NHS which is under strain. But we now have fewer treatment options than we did 14 years ago. We must effectively communicate and maximise the use of treatments that are currently available, as well as other sources of information on managing osteoarthritis. That said, I want to shout from the rooftops that we should not rest or accept the status quo.
With Versus Arthritis, I recently helped lead a research priority setting exercise in common musculoskeletal conditions like osteoarthritis which involved patients, clinicians and researchers. The participants told us that their top two research priorities were ‘to develop and test new treatments to prevent or reduce progression’ and ‘to identify the best ways to manage pain and/or improve quality of life’. So, we all agree we have more to do.
Further information on osteoarthritis can be found on the Versus Arthritis website.
Dr Fiona Watt is a Reader in Rheumatology and UKRI Future Leaders Fellow at the Department of Immunology and Inflammation, and an Honorary Consultant Rheumatologist at Imperial College Healthcare NHS Trust. She is also a member of The Centre for Osteoarthritis Pathogenesis Versus Arthritis and the Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis.