Abstract
This review is intended to provide physicians with an overview of the benefits and risks associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of their patients with mild-to-moderate osteoarthritis (OA). New information on the inflammatory component of OA and the cardiovascular (CV) risk associated with cyclooxygenase (COX)-2-specific inhibitors has prompted efforts to revise the current recommendations for the use of NSAIDs in the treatment of patients with OA. Clinical studies have shown that naproxen and ibuprofen are significantly more effective at reducing OA pain than is acetaminophen, the traditional first-line therapy, which has no apparent anti-inflammatory activity in the joints. The theoretical advantage of COX-2-specific inhibitors in reducing gastrointestinal (GI) toxicity has been demonstrated by clinical studies. GI complications can be reduced by using lower NSAID doses for the shortest duration or with a concomitant proton-pump inhibitor. All prescription NSAIDs carry a black box warning regarding CV risks; these risks vary among the NSAIDs. While ibuprofen and diclofenac are associated with an increased CV risk, naproxen was associated with a neutral CV risk relative to placebo. Ibuprofen, but not naproxen, attenuates the antiplatelet effects of aspirin. An understanding of the risks and benefits is important when choosing an NSAID. An exhaustive search of the medical literature since 1990 was conducted using the words "ibuprofen," "naproxen," "COX-2-specific NSAIDs," "nonspecific NSAIDs," "low-dose aspirin," and "nonprescription dosage." Databases searched included MEDLINE, EMBASE, and SCISEARCH. This article provides primary care physicians with the information needed to assist them in making more informed decisions in managing patients experiencing mild-to-moderate OA pain.
Highlights
Patients with musculoskeletal diseases such as osteoarthritis (OA) are typically managed with a combination of nonpharmacologic modalities and pharmacologic agents that are chosen to pose a minimal risk of side effects
The Celecoxib Long-term Arthritis Safety Study (CLASS), which combined the results from two prospective trials comparing celecoxib with diclofenac and ibuprofen, showed no significant difference between the groups in the rate of upper GI ulcer complications (0.7% for patients receiving celecoxib versus 1.5% for patients receiving either of the nonselective Nonsteroidal anti-inflammatory drugs (NSAIDs))[27,28,29]
The important point to note in these 2008 guidelines is that acetaminophen is used for the treatment of mild-to-moderate pain, while NSAIDs are recommended in symptomatic patients who have both pain and inflammation
Summary
Patients with musculoskeletal diseases such as osteoarthritis (OA) are typically managed with a combination of nonpharmacologic modalities and pharmacologic agents that are chosen to pose a minimal risk of side effects. The updated 2000 ACR guidelines recommended COX-2specific inhibitors as second-line treatment choices after acetaminophen[45] This recommendation was based on the improved GI safety of these agents over that of nonselective NSAIDs, especially in high-risk populations. The important point to note in these 2008 guidelines is that acetaminophen is used for the treatment of mild-to-moderate pain, while NSAIDs are recommended in symptomatic patients who have both pain and inflammation These updated recommendations are based on previously cited data[16,17] showing that analgesics such as acetaminophen relieve pain but do not provide anti-inflammatory activity within the joint. For patients without CV risk but with elevated risk for GI complications and who are not taking aspirin, the recommended treatment is monotherapy with a COX-2-specific inhibitor or combination therapy with a nonselective NSAID plus a proton-pump inhibitor to mitigate GI risk[49,50]. If these patients require gastroprotection, a proton-pump inhibitor is again suggested; COX-2-specific inhibitors should be avoided in these patients[25,48]
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