Oral Nonsteroidal Anti-inflammatory Drugs Research Articles

Schmorl Node-A Cause of Acute Thoracic Pain: A Case Report and Pathophysiological Mechanism.

We report a case of a patient with an acute symptomatic Schmorl node (SN) that spontaneously resolved with characteristic imaging findings. The extensive hematological investigations also allow some insight as to the likely pathophysiology of the painful lesion. Case report of an acute symptomatic SN. A fit and athletic 44-year-old female participant in a competitive paddling event developed atypical thoracic pain and was admitted for further investigation. Normal blood results included complete blood cell count, clotting, and D-dimer. Creatine phosphokinase was 63 U/L (reference < 167 U/L) and troponin I levels were not raised. Her only hematological abnormality was an elevated C-reactive protein (CRP) at 60.2 mg/L (reference < 5 mg/L). Magnetic resonance imaging (MRI) scan showed signal hyperintensity involving T7 vertebral body, surrounding an enlarged SN. Patient was given oral nonsteroidal anti-inflammatory drugs, opioid analgesia, and gradually mobilized. After 3 days, the pain had sufficiently subsided and CRP was 17.8 mg/L. Follow-up MRI scan showed some reduction in the T2 hyperintensity and size of the intraosseous herniation. Patient gradually returned to full activities and had no recurrence of symptoms. MRI scan 8 months after the initial scan showed almost complete resolution of the T2 hyperintensity and pan-vertebral marrow edema. Symptomatic SN should be part of the differential diagnosis of unexplained thoracolumbar pain. Modality of choice for diagnosis would be MRI. Once diagnosed, several treatment options are available with the most likely being spontaneous resolution of symptoms and bone healing within a few months. The conservative approach is recommended when the symptoms can be medically well controlled.

Longitudinal Assessment of Pain Management Among the Employed Japanese Population with Knee Osteoarthritis.

PurposeTo assess comorbidity burden and pain-management patterns among working-aged patients with knee osteoarthritis only (KOA/O) and patients with knee osteoarthritis plus osteoarthritis at another site (KOA/+) in Japan.Patients and MethodsRetrospective claims data analysis was conducted using the Japan Medical Data Center database. Working-aged adults (aged 40 to 71 years) with 5 years of follow-up and diagnosed with knee osteoarthritis (KOA) between January 1, 2011, and December 31, 2012, were evaluated. The first claim with a KOA diagnosis defined the index date. Patients were divided into two mutually exclusive cohorts: KOA/O and KOA/+. Longitudinal pain-management patterns during each year of follow-up were analyzed.ResultsA total of 2542 patients met study criteria: 1575 KOA/O and 967 KOA/+. Mean age and number of comorbidities were higher among the KOA/+ versus KOA/O cohort. Pharmaceutical treatment was received by 91.5% of patients in the KOA/+ compared with 85.1% of patients in the KOA/O cohort during the first year of follow-up. The most common pharmacological treatment received during the first year of follow-up was either topical or oral nonsteroidal anti-inflammatory drugs for both cohorts. During each year of follow-up, the KOA/+ cohort had greater proportion of patients with at least one health-care encounter (ie, hospital admissions, outpatient and pharmacy visits) and higher direct medical costs compared with the KOA/O cohort.ConclusionThis study demonstrates that a greater proportion of the working population with KOA/+ received pain-related treatment compared with patients with KOA/O. Further studies are necessary to evaluate appropriate pain management for both KOA only and KOA with other sites.

Epidemiology of episcleritis and scleritis in urban Australia

The epidemiology of episcleritis and scleritis in Australia is largely unknown. To determine the incidence, prevalence and clinical characteristics of episcleritis and scleritis in Melbourne. Retrospective longitudinal study. Patients aged ≥18 years with episcleritis or scleritis seen at the Royal Victorian Eye and Ear Hospital from November 2014 to October 2015. Medical record review confirmed clinical diagnosis and characteristics. Incidence and prevalence were calculated using estimates of the adult population in areas of Melbourne with ≥30 ocular presentations/year to the emergency department. Diagnosis of active episcleritis or scleritis, aetiology, ocular complications and treatments. From a general population of 3 408 068, we confirmed 149 new and 23 pre-existing cases of active episcleritis, and 35 new and 23 pre-existing cases of active scleritis. Incidence per 100 000 person-years was 4.4 (95% confidence interval [CI] 3.7-5.1) for episcleritis and 1.0 (95% CI 0.7-1.4) for scleritis, while 12-month prevalence was 5.1 (95% CI 4.3-5.9) and 1.7 (1.3-2.2) per 100 000 persons, respectively. Systemic disease was associated with 10% of episcleritis compared with 34% of scleritis (P < .001). Ocular complications were seen in 3% (6/184) of episcleritis eyes and 44% (32/72) of scleritis eyes, with the commonest being anterior uveitis (12/72) and ocular hypertension (14/72). At presentation, scleritis patients were commonly treated with oral non-steroidal anti-inflammatory drugs (60%) and prednisolone (19%). By 12 months, 24% of scleritis patients required immunosuppressants. Rates of episcleritis and scleritis in our single-centre Australian study were low. Episcleritis was usually benign, whereas scleritis had increased ocular complications and systemic disease.

Survey of Postoperative Pain in Photorefractive Keratectomy Using Topical versus Oral Nonsteroidal Anti-Inflammatory Drugs.

PurposeTo evaluate and compare postoperative pain following photorefractive keratectomy (PRK) in patients using a preventive regimen of oral versus topical nonsteroidal anti-inflammatory drugs (NSAIDs).Patients and MethodsA prospective, randomized, longitudinal survey of postoperative PRK pain was performed on 157 subjects in a tertiary academic medical center setting. Patients were randomized to either topical ketorolac 0.4% every 12 hours or oral naproxen sodium 220 mg every 12 hours for 72 hours following PRK, beginning at the time of surgery. The primary outcome measure was the daily peak pain score from the validated numerical rating scale (NRS) for five days after surgery.ResultsThe peak pain scores were significantly higher in the oral NSAID group (mean 5.82, SD 1.94) compared to the topical NSAID group (mean 4.2, SD 2.19) (p<0.0001) after PRK. When comparing each postoperative day after PRK, the pain scores from 24 to 48 hours (day 2) were significantly higher in the oral NSAID group (mean 5.17, SD 2.25) as compared to the topical NSAID group (mean 3.21, SD 2.09) (p<0.0001). Pain scores 24–72 hours after surgery (days 2 and 3) were higher than pain scores on days 1, 4, and 5 for both groups.ConclusionTwice daily oral naproxen sodium 220 mg is inferior to twice daily topical ketorolac 0.4% in the treatment of early postoperative pain after PRK. This study also identified a consistent trend in which pain scores were highest 24–72 hours after the procedure. This additional observation may be useful in understanding, preventing, and treating post-PRK pain.

Efficacy and safety of different nonsteroidal anti-inflammatory drugs for acute neck and back pain

Objective: to comparatively study several nonsteroidal anti-inflammatory drugs (NSAIDs) (their analgesic effect; dynamics of quality of life; side effects, such as NSAID-gastropathy and gastric dyspepsia) in acute pain in the neck and back (dorsalgia). Patients and methods. The investigators followed up 120 patients (4 groups, each having 30 people) with acute dorsalgia who took different oral NSAIDs for 7 days: long-acting ketoprofen, aceclofenac, naproxen, and dexketoprofen (Flamadex). To evaluate their possible side effects, dyspepsia symptoms were monitored and blood pressure (BP) was measured daily; gastroscopy was repeated after completion of a treatment cycle. The Nottingham Quality of Life Questionnaire and the Visual Analogue Scale (VAS) for pain were used. Results and discussion. A gradual and substantial reduction in pain measured according to VAS was noted in all the NSAID-treated groups. The intensity of pain syndrome decreased faster in the dexketoprofen group; the analgesic effect of naproxen and long-acting aceclofenac was significantly less (p=0.012 and 0.002, respectively). This patient group showed a tendency to maximum improvement according to the Nottingham Quality of Life Questionnaire and VAS. Elevated BP was observed in all the groups, but statistically significantly more frequently in the naproxen group (p=0.05). Gastric dyspepsia was also registered in all the groups, but a tendency to its lower frequency was seen in the dexketoprofen group. Conclusion. Dexketoprofen showed fewer side effects and a more pronounced analgesic effect than ketoprofen, aceclofenac, and naproxen in acute dorsalgia.

Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm.

Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes. A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria. A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports. A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.

Duration of Symptom Relief and Early Trajectory of Adverse Events for Oral Nonsteroidal Antiinflammatory Drugs in Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

Despite an extensive body of research on nonsteroidal antiinflammatory drugs (NSAIDs) in osteoarthritis, the duration of their efficacy and timeline of adverse event (AE) onset have been understudied. We conducted a systematic review and meta-analyses from 2 to 26 weeks to characterize the efficacy and AE trajectories of oral NSAIDs in knee osteoarthritis. We searched MEDLINE, Embase, Web of Science, Google Scholar, and the Cochrane Database from inception to May 2018. Randomized controlled trials assessing the efficacy and/or safety of Federal Drug Administration-approved NSAIDs in knee osteoarthritis patients were included. Two independent reviewers assessed quality and extracted data. We calculated standardized mean differences (SMDs) and risk ratios (RRs) with 95% confidence intervals (95% CIs). We included 72 randomized controlled trials (26,424 participants). NSAIDs demonstrated moderate, statistically significant effects on pain that peaked at 2 weeks (SMD -0.43 [95% CI -0.48, -0.38]), but the magnitude of the effects decreased over time. The results for function were similar. The incidence of gastrointestinal (GI) AEs was significantly higher in NSAID users than placebo users as early as 4 weeks (RR 1.38 [95% CI 1.21, 1.57]). The incidence of cardiovascular (CV) AEs in NSAID users was not significantly different from placebo. Most GI and CV AEs were transient and of minor severity. NSAIDs produced significant pain and function improvements that peaked at 2 weeks but decreased over time. The incidence of minor GI and CV AEs consistently rose, reaching significance as early as 4 weeks. Clinicians should weigh the durability of efficacy with the early onset of minor AEs along with patient tolerability and preferences when formulating an NSAID regimen.

Effect of Flurbiprofen and S-Flurbiprofen Patches on Multimodal Pain Management After Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

BackgroundTotal knee arthroplasty (TKA) is an established procedure for knee osteoarthritis. Multimodal analgesia is reportedly more effective for postoperative analgesia. We investigated the efficacy of 2 patches after TKA. MethodsSeventy-nine knees that underwent unilateral TKA for osteoarthritis were included. Oral administration, local periarticular analgesic injection, and patches were adopted for pain management. The knees were randomly assigned to the flurbiprofen patch (FPP), S-flurbiprofen patch (SFPP), and control (no patch) groups. Patch treatment was continued for 14 days. Pain according to the visual analog scale, knee flexion angle, renal dysfunction, gastrointestinal injury, duration of hospitalization, dermatitis, and the rate of using additional oral nonsteroidal anti-inflammatory drugs were compared (from preoperative to postoperative day 14). ResultsThe FPP, SFPP, and control groups included 29, 27, and 23 knees, respectively. Visual analog scale was lower in the FPP and SFPP groups than in the control group on days 1 and 3 (day 1: 24.4, 25.0, and 39.4, respectively; day 3: 25.5, 23.3, and 39.3, respectively). Knee flexion angle was larger in the SFPP group than in the control group on days 7 and 14 (day 7: 89.8° and 76.6°, respectively; day 14: 98.3° and 84.2°, respectively). Neither renal dysfunction nor gastrointestinal injury was confirmed. The duration of hospitalization did not differ among the groups. Dermatitis occurred only in the SFPP group. The rate of using additional oral nonsteroidal anti-inflammatory drugs was higher in the control group. ConclusionBoth patches were effective and safe as part of multimodal analgesia for postoperative TKA.

A comparative analysis of the efficacy of intra-articular injections of corticosteroid, hyaluronic acid and platelet-rich plasma for the treatment of osteoarthritis knee

Background: Osteoarthritis (OA) of the knee is the most common chronic degenerative joint disease characterized by pain, stiffness, swelling and progressive functional limitation in elderly. Non-surgical management modalities like physical therapy, lifestyle modification and oral non-steroidal anti-inflammatory drugs, are often ineffective or do not alleviate symptoms adequately. Intra-articular corticosteroid (CS) and hyaluronic acid (HA) injections have been used for long to alleviate the symptoms of knee OA. Recently platelet-rich plasma (PRP) therapy has also been tried widely. Very few researches involving a comparison of the three have been conducted. The purpose of the present study was to evaluate the therapeutic effect, efficacy and safety of intra-articular corticosteroid, hyaluronic acid and platelet-rich plasma for knee osteoarthritis. Methods: 90 patients (132 knees) with primary knee osteoarthritis were randomized to receive one injection of intra-articular corticosteroid, hyaluronic acid or platelet-rich plasma and were followed for 3 months. The two groups were compared as regards pain and functional improvement using the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), and the visual analog pain scale (VAS), by assessing the patients three times. Results: VAS scale showed that all three modalities were effective in pain reduction. Both WOMAC and KOOS score represented variably improved symptoms i.e. decrease in pain and stiffness along with improvement in daily activity after 3 months in all 3 groups. Conclusion: As the degree of pain relief achieved by the respective modalities was almost similar, the most important difference between the three intervention groups was the duration of their effectiveness. HA is suggested to be superior in the duration of pain relief when compared to CS and PRP. We can propose that HA can be administered less often as compared to CS and PRP for knee joint OA. Therefore, it will be more convenient to use HA.

Efficacy and Safety of Diclofenac + Capsaicin Gel in Patients with Acute Back/Neck Pain: A Multicenter Randomized Controlled Study.

IntroductionBack and neck pain are common musculoskeletal disorders. Topical non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used to reduce pain and inflammation with fewer systemic side effects and drug interactions compared with oral NSAIDs. This study assessed efficacy and tolerability of a topical combination of capsaicin + diclofenac to treat acute back/neck pain.MethodsIn a randomized, double-blind, controlled, multicenter, parallel group trial, 746 patients were treated twice-daily for 5 days with diclofenac 2% + capsaicin 0.075%, diclofenac 2%, capsaicin 0.075% or placebo. Efficacy assessments included change and area under the curve in pain on movement for the worst procedure (POMWP), change in pressure algometry, and number of patients with decrease in POMWP of ≥ 30% and ≥ 50%. Adverse events (AEs) were recorded.ResultsChange in POMWP between baseline and day 2 evening, 1 h after drug application, demonstrates superiority of the combination (− 3.05 cm) versus diclofenac alone (− 2.33 cm) and placebo (− 2.45 cm), but not capsaicin alone (− 3.26 cm). AEs were consistent with known safety profiles.ConclusionCapsaicin alone and capsaicin + diclofenac showed superior benefit compared with placebo. However, diclofenac alone demonstrated efficacy comparable with placebo, and therefore its addition to capsaicin added no increased pain relief over capsaicin alone.Trial registrationClinicalTrials.gov identifier; NCT02700815.Electronic supplementary materialThe online version of this article (10.1007/s40122-020-00161-9) contains supplementary material, which is available to authorized users.

Effect of α-adrenergic blockers silodosin in the management of distal ureteric calculus

Background: Urinary calculus disease is one of the 3 most common urological diseases. It affects about 12% of the world population and has become a worldwide health problem. Of all the urinary tract stones 20% are ureteral stones, of which 70% are found in the distal ureter. The objective of the study is to study the effect of silodosin in the passage of calculi in the distal ureter compared to non-steroidal anti-inflammatory drugs (NSAIDs) (diclofenac sodium) and oral fluids.Methods: This study included a total of 90 patients between the study period from October 2016 to October 2018. 45 patients were chosen randomly and advised to take plenty of oral fluids and treated with NSAIDs and the other 45 patients were treated with silodosin 8 mg HS for one month along with oral fluids and NSAIDs. After 1 month if the stone was passed successfully, it was confirmed with ultrasonography, if failed, advised for surgery.Results: Majority of the patients were in the age group of 20-45 yrs. The mean size of the calculus was 5.60 cm on the right side and 5.71 cm on the left side. Out of the 45 patients who were on treatment with silodosin 35 patients had passed the calculi and 10 patients had no results with a success rate of 77.7%. In the 45 patients who were not on silodosin, 8 patients passed the calculi and 37 patients did not pass the calculi. 21 patients among the 45 underwent urethrorenoscopy.Conclusions: Silodosin is an effective and safe drug in the management of calculi in the distal ureter.

Topical Diclofenac, an Efficacious Treatment for Osteoarthritis: A Narrative Review.

Multiple head-to-head trials have demonstrated that topical nonsteroidal anti-inflammatory drugs (NSAIDs), including topical diclofenac, provide at least equivalent analgesia, improvement in physical function, and reduction of stiffness compared with oral NSAIDs in osteoarthritis and have fewer systemic adverse events. While efficacy of topical diclofenac in osteoarthritis is well established, understanding of the time to onset of action, duration of effect, and the minimum effective concentration is limited. Factors likely to influence these parameters include drug penetration and localization. Diclofenac concentrations in the joint tissues are likely to be more relevant than plasma concentrations. However, although diclofenac penetrates and is retained in these “effect compartments” at the site of inflammation and drug activity, no specific minimum effective concentration of diclofenac in plasma or synovial tissue has been identified. Recent evidence suggests that a reduction in inflammatory markers may be a better predictor of efficacy than plasma concentrations. This narrative review explores existing evidence in these areas and identifies the gaps where further research is needed. Based on our findings, topical NSAIDs such as diclofenac should be considered as a guideline-supported, generally well-tolerated, and effective first-line treatment option for knee and hand OA, especially for older patients and those who have comorbid conditions and/or risk factors for various systemic (gastrointestinal, hepatic, renal, or cardiovascular) adverse events associated with oral NSAIDs, particularly at high doses and with long-term use.Electronic supplementary materialThe online version of this article (10.1007/s40744-020-00196-6) contains supplementary material, which is available to authorized users.

How do oral non-steroidal anti-inflammatory drugs affect outcomes in people with cystic fibrosis lung disease?

How do oral non-steroidal anti-inflammatory drugs affect outcomes in people with cystic fibrosis lung disease?

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.

To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.

To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

Hyaluronic Acid Injections or Oral Nonsteroidal Anti-inflammatory Drugs for Knee Osteoarthritis: Systematic Review and Meta-analysis of Randomized Trials

Background:Intra-articular hyaluronic acid (HA) injections and oral nonsteroidal anti-inflammatory drugs (NSAIDs) are common treatments for symptomatic knee osteoarthritis (OA). However, the comparative effects of these treatments are unclear.Purpose:To compare the efficacy and safety of intra-articular HA injections compared with oral NSAIDs for the treatment of knee OA.Study Design:Systematic review; Level of evidence, 1.Methods:We systematically searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for randomized trials of knee OA treatment with HA injections compared with oral NSAIDs. The main outcomes were knee pain, knee function, adverse events (AEs), serious AEs, study withdrawals, and study withdrawals because of AEs. Pooled effect sizes were reported at the final follow-up with standardized mean difference (SMD) for efficacy outcomes and risk ratio (RR) for safety outcomes.Results:In 6 randomized trials of 831 patients (414 HA, 417 NSAIDs), with follow-up ranging from 5 to 26 weeks, HA injections were associated with small, statistically significant improvements in knee pain (SMD, 0.15; P = .04) and knee function (SMD, 0.23; P = .01) compared with oral NSAIDs. The risk of AEs was lower with HA compared with NSAIDs (19.8% vs 29.0%; RR, 0.74; P = .01). The risk of a serious AE (RR, 1.37; P = .71), study withdrawal (RR, 1.05; P = .68), or study withdrawal because of an AE (RR, 0.65; P = .22) was comparable between groups. Gastrointestinal concerns were the most frequent AE reported, occurring more often with NSAIDs (23.4% vs 14.1%; P = .001). AEs reported more frequently with HA injections were injection site pain (11.7% vs 4.7%; P < .001), headache (8.4% vs 4.4%; P = .03), and arthralgia (8.1% vs 2.9%; P = .001). Significant heterogeneity or publication bias was not observed for any outcome.Conclusion:Comparing short-term outcomes of HA injections with oral NSAIDs for treatment of knee OA, HA injections provided statistically significant but not clinically important improvements in knee pain and function, along with a lower overall risk of AEs.

Expert Opinion on the Extensive Use of Prescription Crystalline Glucosamine Sulfate in the Multimodal Treatment of Osteoarthritis in Ukraine, Kazakhstan, Uzbekistan, and Armenia.

Objective:The present work was led by a multidisciplinary panel of experts and proposes an extensive review on the use of prescription crystalline glucosamine sulfate (pCGS) in the multimodal treatment of osteoarthritis (OA) applicable in Ukraine and other Commonwealth of Independent States (CIS) countries.Methods:A panel of rheumatologists, orthopedic surgeons, and field experts from Ukraine and CIS regions discussed the management of OA. Literature was systematically searched using Medline, EMBASE, CIHNAL, and Cochrane Library databases. The 2-day meeting critically reviewed the available literature, treatment algorithms, pharmacoeconomic aspects, and real-world instances to form a multimodal approach based both on real-life clinical practice and systematic literature research for the management of OA in Ukraine and CIS countries.Expert Opinion:pCGS plays a pivotal role in the stepwise approach to OA treatment. If it is necessary (step 1), the combined use of pCGS with paracetamol and topical nonsteroidal anti-inflammatory drugs (NSAIDs) has been recommended. If symptoms persist, oral NSAIDs and intra-articular (IA) hyaluronic acid or corticosteroids are added to the therapy (step 2) of pCGS in the patients. In case of insufficient relief and severe OA (step 3), pCGS along with oral NSAIDs, IA corticosteroids, and duloxetine have been recommended. Patient stratification with regular monitoring and careful alterations in treatment were advocated.Conclusions:This expert opinion article recommends a modified approach to the existing guidelines incorporating pCGS in treatment modality of OA in Ukraine and CIS countries. Extensive use of pCGS targets early symptomatic relief in OA while limiting the adverse effects due to long-term use of analgesics and NSAIDs.

Etoricoxib

Etoricoxib is an oral nonsteroidal anti-inflammatory drug (NSAID). It acts as a selective cyclo-oxygenase-2 (COX-2) inhibitor with anti-inflammatory, analgesic and antipyretic properties. Etoricoxib is available as a tablet formulation in strengths of 60 mg, 90 mg or 120 mg.

Effect of fluoroscopically guided corticosteroid injection versus oral nonsteroidal anti-inflammatory drugs for treatment of coccydynia: A randomized, controlled, single-blind study

Background: Coccydynia is a major cause of coccyx pain that can result in chronic pain as well as reduced functional performance in patients. The aim of this study was to compare the efficacy of fluoroscopically guided corticosteroid injection with an oral nonsteroidal anti-inflammatory drug (NSAID) to relieve coccyx pain. Methods: In a clinical trial study, 28 patients with coccydynia who were randomly divided into two groups and matched based on sex, age, and body mass index. One group was treated with celecoxib 200 mg (every 12 hr) for 1 mo along with regular use of a tailbone pillow while sitting on hard surfaces. The second group received local periarticular injection of methylprednisolone acetate 40 mg along with lidocaine 1%, which was fluoroscopically guided. The patients were followed for 4 mo. Results: There was a significant difference in pain severity of the patients when compared with their condition at the beginning of the study in each group (P&lt;0.001). The final pain severity of NSAID group and steroid group was 37.9±14.2 mm and 38.7±16.1 mm, respectively, which was not significantly different. Also the trend of pain severity was similar between the two groups. Conclusions: Corticosteroid injection for coccydynia treatment at least has the same advantages of oral NSAID medication. Regarding its single-dose administration and reasonable price, it can be considered as an alternative modality in treatment of this disease if the target patient is selected correctly. Level of Evidence: Level I.

Prospective, open-label, randomized, parallel group, comparative clinical study of two topical formulations of diclofenac diethylamine in the treatment of acute painful musculoskeletal conditions

Background: Oral nonsteroidal anti-inflammatory drugs have been used in the management of musculoskeletal pain due to inconsistent skin penetration of topical formulations. The quick penetrating solution of diclofenac is a novel topical solution of diclofenac diethylamine (4.64%), which has increased skin penetration. The present study was designed to compare the efficacy and safety of quick penetrating solution of diclofenac with diclofenac gel in patients with acute musculoskeletal pain. Materials and Methods: A randomized controlled clinical trial was conducted in 140 patients suffering from acute musculoskeletal pain who were randomized to receive diclofenac diethylamine 4.64% w/v topical solution (Group A) or diclofenac diethylamine 1.16% gel (Group B). The pain intensity difference (PID) between patients in both groups at rest and during movement of the affected area on day 3 and day 7 after injury was noted using the visual analog scale (VAS) and were compared with the baseline. A comparison of the requirement of oral rescue analgesics and adverse effects in both groups was also carried out. Results: The PID in VAS from baseline was significantly better in patients in Group A than patients in Group B on days 3 (3.74 and 2.42;P