Osteoarthritis: Topic of the Day

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osteoarthritis

Hand Osteoarthritis

  • Oral and topical NSAIDs - (in patients 75 and older topical NSAIDs are preferred)
  • Topical Capsaicin
  • Tramadol

**Opioids and intra-articular therapies are not recommended. 

Knee Osteoarthritis

  • Aerobic or resistance land-based exercise, aquatic exercise and weight loss
  • For moderate to severe pain in patients who don't elect joint replacement, acupuncture and TENS recommended.
  • Pharmacological: Oral and topical NSAIDs, tramadol, and intra-articular corticosteroid injections

**Glucosamine, chondroitin sulfate, and topical capsaicin were conditionally not recommended

Hip Osteoarthritis

Treat similar to those with knee osteoarthritis

Tramadol and intra-articular corticosteroid injections have been upgraded to initial OA treatment, while previous guidelines listed only APAP as first-line.

 

NOTES:

  • COX-2 inhibitor celecoxib (Celebrex) or a traditional NSAID along with a stomach-protective drug, such as esomeprazole (Nexium) or omeprazole (Prilosec) for younger people at high risk of gastrointestinal side effects
  • Opioids such as hydrocodone for people who don’t respond to other treatments and aren’t candidates for joint replacement; (The panel cautioned that doctors who prescribe them should follow guidelines established by the American Pain Society and the American Academy of Pain Medicine.
  • Tai chi, acupuncture, TENS (transcutaneous electrical nerve stimulation) or intra-articular hyaluronate injections for knee OA, but not hip OA. 

Special Populations

  • For persons age ≥75 years, the Technical Expert Panel (TEP) strongly recommends the use of topical rather than oral nonsteroidal anti-inflammatory drugs (NSAIDs).
  • In the clinical scenario where the patient with osteoarthritis (OA) is taking low-dose aspirin (≤325 mg per day) for cardioprotection and the practitioner chooses to use an oral NSAID, the TEP strongly recommends using a nonselective NSAID other than ibuprofen or COX-2 inhibitor** in combination with a proton-pump inhibitor. This recommendation is based, in part, on the Food and Drug Administration (FDA) warning that the concomitant use of ibuprofen and low-dose aspirin may render aspirin less effective when used for cardioprotection and stroke prevention because of a recognized pharmacodynamic interaction. **Studies have not demonstrated this same type of pharmacodynamic interaction with diclofenac or celecoxib; nonetheless, the TEP strongly recommends that a cyclooxygenase 2 (COX-2) selective inhibitor should not be used in the above situation as well.
  • The decision to use an oral NSAID in patients with chronic kidney disease stage III (estimated glomerular filtration rate between 30 and 59 cc/minute) should be made by the practitioner on an individual basis after consideration of the benefits and risks. 

Contraindications

Based on good clinical practice, oral nonsteroidal antiinflammatory drugs (NSAIDs) should not be used in patients with chronic kidney disease stage IV or V (estimated glomerular filtration rate below 30 cc/minute).

ACR elevates NSAIDs to a first-line option 2012 updates: Recommendations for knee and hip OA now include NSAIDs as first-line pharmacological options, with the consideration of adding PPIs to reduce potential GI toxicity in cases of chronic NSAID use.

ACR continues to caution against exceeding a daily 4-g dose of acetaminophen. (FDA cautions against >3 grams/APAP per day).