Topical Nonsteroidal Anti-inflammatory Drugs Research Articles

Topical NSAID Formulations

This article reviews topical nonsteroidal anti-inflammatory drug (NSAID) formulations available in the United States, including advantages and disadvantages, therapeutic usefulness, adverse effects, and formulation considerations. In the United States, several topical NSAID products are approved to treat painful conditions including diclofenac sodium 1% gel (Voltaren Gel®; Endo Pharmaceuticals), diclofenac sodium topical solution 1.5% w/w in 45.5% dimethyl sulfoxide (PENNSAID®; Mallinckrodt, Inc.), and diclofenac epolamine 1.3% (Flector Patch®; Alpharma Pharmaceuticals LLC, a subsidiary of Pfizer, Inc.). Recent studies suggest topical diclofenac preparations are effective for osteoarthritis pain and suggest the efficacy of topical formulations is similar to that achieved with oral NSAID formulations. All NSAID formulations contain the same boxed warnings regarding cardiovascular and renal toxicity; however, topical NSAIDs are proposed to have a more favorable safety profile than oral NSAIDs due to the low serum concentrations achieved with topical NSAID formulations. Topical NSAIDs have been shown to be beneficial from both a therapeutics and adverse effect perspective, and are increasingly recommended in treatment guidelines.

Quality indicators for the primary care of osteoarthritis: a systematic review.

ObjectiveTo identify valid and feasible quality indicators for the primary care of osteoarthritis (OA).DesignSystematic review and narrative synthesis.Data sourcesElectronic reference databases (MEDLINE, EMBASE, CINAHL, HMIC, PsychINFO), quality indicator repositories, subject experts.Eligibility criteriaEligible articles referred to adults with OA, focused on development or implementation of quality indicators, and relevant to UK primary care. An English language restriction was used. The date range for the search was January 2000 to August 2013. The majority of OA management guidance has been published within this time frame.Data extractionRelevant studies were quality assessed using previous quality indicator methodology. Two reviewers independently extracted data. Articles were assessed through the Outcome Measures in Rheumatology filter; indicators were mapped to management guidance for OA in adults. A narrative synthesis was used to combine the indicators within themes.Results10 853 articles were identified from the search; 32 were included in the review. Fifteen indicators were considered valid and feasible for implementation in primary care; these related to assessment non-pharmacological and pharmacological management. Another 10 indicators were considered less feasible, in various aspects of assessment and management. A small number of recommendations had no published corresponding quality indicator, such as use of topical non-steroidal anti-inflammatory drugs. No negative (‘do not do’) indicators were identified.Conclusions and implications of key findingsThere are well-developed, feasible indicators of quality of care for OA which could be implemented in primary care. Their use would assist the audit and quality improvement for this common and frequently disabling condition.

Benzydamine hydrochloride on postoperative sore throat: a meta-analysis of randomized controlled trials

Sore throat is a common postoperative complaint. The etiology of postoperative sore throat (POST) is considered the result of damage to airway mucosa after insertion of a laryngeal mask airway device or endotracheal tube. This paper proposes benzydamine hydrochloride (BH), a topical nonsteroidal anti-inflammatory drug (NSAID) with additional analgesic and local anesthetic properties, for POST prevention. We systematically searched PubMed, EMBASE™, Cochrane, and other relevant databases for randomized controlled trials (RCTs) that investigated the outcome of topical application of BH vs non-application in patients undergoing general anesthesia. Using a random effects model, meta-analyses were conducted to assess the relative risks of the incidence of POST within 24 hr following the surgical procedure. The secondary outcomes included postoperative nausea and vomiting, dry mouth, coughing, and local irritation. We reviewed five trials that included 824 patients in total. Our results indicated that the incidence of POST was significantly reduced in the BH group, with risk ratios (RRs) of 0.37 (95% confidence interval [CI]: 0.20 to 0.68) at zero to one hour, 0.39 (95% CI: 0.27 to 0.57) at one to two hours, 0.42 (95% CI: 0.22 to 0.81) at four to six hours, 0.29 (95% CI: 0.10 to 0.88) at six to 12 hr, and 0.32 (95% CI: 0.18 to 0.56) at 12 to 24 hr, compared with the control groups. Patients reported local irritation, but no major BH-related complications were observed. Our results indicate that the incidence of POST can be significantly reduced by prophylactic BH topical application to the oral cavity or airway devices. Further RCTs are required to overcome the limitations of heterogeneity and to determine the optimal dosage and application of BH for managing POST.

Viscosupplementation for Osteoarthritis: a Primer for Primary Care Physicians

Osteoarthritis (OA) constitutes a growing public health burden and the most common cause of disability in the United States. Non-pharmacologic modalities and conservative pharmacologic therapies are recommended for the initial treatment of OA, including acetaminophen, and topical and oral non-steroidal anti-inflammatory drugs. However, safety concerns continue to mount regarding the use of these treatments and none have been shown to impact disease progression. Viscosupplementation with injections of hyaluronans (HAs) are indicated when non-pharmacologic and simple analgesics have failed to relieve symptoms (e.g., pain, stiffness) associated with knee OA. This review evaluates literature focusing on the efficacy and/or safety of HA injections in treating OA of the knee and in other joints, including the hip, shoulder, and ankle. Relevant literature on intra-articular (IA) HA injections as a treatment for OA pain in the knee and other joints was identified through PubMed database searches from inception until January 2013. Search terms included "hyaluronic acid" or "hylan", and "osteoarthritis". Current evidence indicates that HA injections are beneficial and safe for patients with OA of the knee. IA injections of HAs treat the symptoms of knee OA and may also have disease-modifying properties, potentially delaying progression of OA. Although traditionally reserved for second-line treatment, evidence suggests that HAs may have value as a first-line therapy in the treatment of knee OA as they have been shown to be more effective in earlier stages and grades of disease, more recently diagnosed OA, and in less severe radiographic OA. For primary care physicians who treat and care for patients with OA of the knee, IA injection with HAs constitutes a safe and effective treatment that can be routinely administered in the office setting.

Posterior Subtenon Injection of Triamcinolone Acetonide after Phacoemulsification in a Patient with X-Linked Retinoschisis

To describe a case of X-linked retinoschisis with pseudophakic cystoid macular edema treated by posterior subtenon injection of triamcinolone acetonide. The patient was a 60-year-old man. His best-corrected visual acuity (BCVA) was counting fingers in the right eye. Senile cataract was found with grade II nuclear sclerosis. Optical coherence tomography revealed foveoschisis with a central foveal thickness (CFT) of 545 μm. The patient underwent uneventful phacoemulsification and in-the-bag implantation of intraocular lens. Postoperative persistent cystoid macular edema was found, with CFT increased to 787 μm. The macular edema did not respond to topical corticosteroids and nonsteroidal anti-inflammatory drugs. Triamcinolone acetonide 20 mg was injected into the posterior subtenon space 10 weeks after the surgery. Macular cystic lesions dramatically disappeared 2 months after the injection, and CFT decreased to 171 μm, with accompanying inner/outer segment disruption. His BCVA also improved to 20/100. Macular edema or foveoschisis did not recur, and BCVA remained stable 1 year after the cataract operation. Foveoschisis and pseudophakic cystoid macular edema disappeared after posterior subtenon injection of triamcinolone acetonide without recurrence during the 15-month follow-up period.

Clinical Pearls

Clinical Pearls

Evidencias para el uso de antiinflamatorios no esteroideos tópicos

Evidence for the use of topical non-steroidal anti-inflammatory drugs. OBJECTIVE. To analyse the efficiency of topical non-steroidal anti-inflammatory drugs (NSAIDs) in patients suffering from acute and chronic osteomuscular pain. METHOD. Analysis of available evidence. Literature search (September 2013) in Medline/Pub

Aqueous Humor Penetration of Ketorolac Formulated in DuraSite or DuraSite 2 Delivery Systems Compared to Acular LS in Rabbits

To evaluate the ocular penetration of ISV-304 (ketorolac tromethamine) formulated in DuraSite(®) or DuraSite(®) 2 compared to Acular LS(®) (0.4% ketorolac ophthalmic solution) in rabbits. The left eye of rabbits received a single topical instillation of either ISV-304 (0.2% and 0.4% ketorolac) in DuraSite, ISV-304 (0.2% and 0.4% ketorolac) in DuraSite 2, or Acular LS. At predetermined time points, aqueous humor (AH) levels of ketorolac were measured by HPLC-MS/MS, and Cmax, Tmax, and AUC0.25-24h were determined. The highest mean concentration of ketorolac was achieved in ISV-304 (0.4%) formulated in DuraSite 2 with a Cmax value of 1889 ± 884 ng/mL, compared to Cmax values for ISV-304 (0.4%) formulated in DuraSite (1212 ± 435 ng/mL) or Acular LS (275 ± 83 ng/mL). ISV-304 (0.2%) formulations also achieved higher AH Cmax values (801 ± 205 ng/mL and 1077 ± 415 ng/mL) compared to Acular LS. There was a significant increase in drug exposure in the ISV-304 (0.4%) formulated in DuraSite 2 or DuraSite formulations with AUC0.25-24h values 6836 ng/mL*h and 5684 ng/mL*h, respectively, compared to Acular LS with an AUC0.25-24h value of 1424 ng/mL*h. ISV-304 (0.2%) formulations also had high AUC0.25-24h values (3241 ng/mL*h and 4490 ng/mL*h), which were a 2.3-3.2-fold increase over the Acular LS AUC0.25-24h value. DuraSite and DuraSite 2 delivery systems markedly improved the ketorolac ocular pharmacokinetic parameters in rabbits. DuraSite formulations may lessen the side effects associated with topical nonsteroidal anti-inflammatory drug use by maintaining efficacy with a reduced dosing regimen and reduced active ingredient.

Interface Haze Associated with Topical Nonsteroidal Anti-Inflammatory Drug Use After Descemet Stripping Automated Endothelial Keratoplasty

To determine if topical nonsteroidal anti-inflammatory drug (NSAID) use after Descemet stripping automated endothelial keratoplasty (DSAEK) is associated with the development of interface haze. A retrospective case-control study of patients undergoing DSAEK surgery. Of the 61 patients receiving topical NSAIDs, 51% were noted to develop interface haze, and 9% of the control group (N=100, no NSAID) developed haze. There was no significant difference in best corrected visual acuity between the 2 groups. Topical NSAID use is associated with the development of interface haze, although it may not be visually significant and could be related to confounding factors.

Managing Osteoarthritis Pain in the Older Population

ABSTRACTChallenges to pharmacological management in this patient group include treatment concordance, comorbidity, polypharmacy, and age-related physiological changes affecting pharmacokinetics. Paracetamol (acetaminophen) is generally recommended as a first-choice analgesic in osteoarthritis pain. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral formulations, and prescribing NSAIDs for older people requires careful consideration. There are some data relating to opioid use for noncancer pain in older people.

The Pharmacology of Topical Analgesics

Pain management of patients continues to pose challenges to clinicians. Given the multiple dimensions of pain – whether acute or chronic, mild, moderate, or severe, nociceptive or neuropathic – a multimodal approach may be needed. Fortunately, clinicians have an array of nonpharmacologic and pharmacologic treatment choices; however, each modality must be chosen carefully, because some often used oral agents are associated with safety and tolerability issues that restrict their use in certain patients. In particular, orally administered nonsteroidal anti–inflammatory drugs, opioids, antidepressants, and anticonvulsants are known to cause systemic adverse effects in some patients. To address this problem, a number of topical therapies in various therapeutic classes have been developed to reduce systemic exposure and minimize the risks of patients developing adverse events. For example, topical nonsteroidal anti–inflammatory drug formulations produce a site–specific effect (ie, cyclo-oxygenase inhibition) while decreasing the systemic exposure that may lead to undesired effects in patients. Similarly, derivatives of acetylsalicylic acid (ie, salicylates) are used in topical analgesic formulations that do not significantly enter the patient's systemic circulation. Salicylates, along with capsaicin, menthol, and camphor, compose the counterirritant class of topical analgesics, which produce analgesia by activating and then desensitizing epidermal nociceptors. Additionally, patches and creams that contain the local anesthetic lidocaine, alone or co–formulated with other local anesthetics, are also used to manage patients with select acute and chronic pain states. Perhaps the most common topical analgesic modality is the cautious application of cutaneous cold and heat. Such treatments may decrease pain not by reaching the target tissue through systemic distribution, but by acting more directly on the affected tissue. Despite the tolerability benefits associated with avoiding systemic circulation, topically applied analgesics are associated with application–site reactions in patients, such as dryness, erythema, burning, and discoloration. Furthermore, some adverse events that have been observed in patients may be suggestive of some degree of systemic exposure. This article reviews the mechanisms of action, pharmacokinetics, and tolerability of topical treatments for the management of patient pain.

Options in Topical Therapies in the Management of Patients With Acute Pain

The traditional cornerstones of analgesic therapy for patients with acute pain have been oral therapies; however, all oral agents exhibit a variety of potentially dose-limiting or intolerable adverse effects in patients. Elderly patients and those with concomitant conditions already being managed with multiple systemic drugs may be particularly susceptible to systemic toxicities with oral analgesic therapies. Topical agents offer an alternative to oral modalities and can effectively treat patients with acute pain while offering lower systemic absorption and conferring little risk of systemic toxicity. The objective of this article is to review the therapeutic usefulness of available topical therapies in their most thoroughly investigated applications, the treatment of patients with acute musculoskeletal and herpetic pain. For example, although heating pads/wraps and cold packs are widely used to alleviate pain associated with sprains, strains, and contusions, evidence of the effectiveness of these methods is lacking. However, there are sufficient data supporting the use of various topical formulations of nonsteroidal anti-inflammatory drugs (NSAIDs) for these indications (ketoprofen gel or patch, ibuprofen gel or cream, and diclofenac gel or patch), and demonstrating markedly less patient risk of systemic toxicity than is associated with oral NSAID therapy. A ketoprofen patch was shown to be effective and well tolerated in the treatment of patients with tendinopathies. In the treatment of acute neck or low back pain, cold and heat therapies have demonstrated limited effectiveness for patients, and the efficacy of topical NSAIDs has not been established. Use of topical NSAID therapy has been useful in reducing acute-phase herpes zoster pain, and the lidocaine 5% patch has been shown to reduce acute herpetic pain intensity once lesions have healed (the patch cannot be applied to open skin lesions). Topical analgesics represent an alternative treatment modality for patients experiencing acute pain who cannot or choose not to take oral therapies.

Effect of topical nonsteroidal anti-inflammatory drugs and corticosteroids on ultraviolet ray-induced erythema

Objective To observe the suppressing effect of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids on ultraviolet ray (UV)-induced erythema.Methods A solar simulator and an UV phototherapy device were used as light sources,respectively.Erythema reaction was induced on the back skin of 30 healthy volunteers by 1,2 and 3 minimal erythema doses (MED) of irradiation.Five preparations including butyl flufenamate 2.5％ ointment,butyl flufenamate 5％ ointment,the base of butyl flufenamate ointment,halometasone ointment,and diclofenac 1％ ointment,were applied to the irradiation sites respectively half an hour before or immediately after the irradiation.One irradiation site remained untreated and served as the control.The degree of erythema was evaluated by a chromameter at 4,24,and 48 hours after the irradiation.Intragroup and intergroup comparisons were done by t test and analysis of variance,respectively.Results When applied half an hour before solar-simulated irradiation,both 2.5％ and 5％ butyl flufenamate ointment totally suppressed the erythema reaction induced by 1-3 MED of UV irradiation,with no significant increase in erythema index at all the three time points after irradiation (all P ＞ 0.05); diclofenac 1％ only inhibited the erythema induced by 1 MED of UV irradiation at 4 and 48 hours,with no difference observed in erythema index between the baseline and these time points after irradiation; however,halometasone significantly aggravated the erythema reaction (P ＜ 0.05).Neither NSAIDs nor corticosteroids applied immediately after solar-simulated irradiation showed statistical effect on the degree of UV-induced erythema.When applied immediately after irradiation using the phototherapy device,butyl flufenamate 2.5％ ointment,butyl flufenamate 5％ ointment and halometasone ointment all induced a significant reduction in erythema reaction at 4 hours after 1 MED of irradiation (all P ＜ 0.05),and diclofenac caused a statistical decrease in erythema reaction at all the time points after 1-3 MED of irradiation (all P ＜0.05).Conclusions Topical use of butyl flufenamate before UV irradiation can effectively inhibit erythema reaction induced by 1-3 MED of irradiation.When applied immediately after irradiation,diclofenac shows the strongest erythema-suppressive effect,followed sequentially by butyl flufenamate and halometasone. Key words: Flufenamic acid; Glucocorticoids; Ultraviolet rays; Erythema

SAT0321 Use of Drug Combinations in Patients with Osteoarthritis: a Population-Based Cohort Study.

BackgroundPatients with osteoarthritis (OA) use different drugs in search for relief, with potential impact on both safety and costs. There is a scarcity of data on drug utilization in these...

Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults

Lateral elbow pain, or tennis elbow, is a common condition that causes pain in the elbow and forearm. Although self-limiting, it can be associated with significant disability and often results in work absence. It is often treated with topical and oral non-steroidal anti-inflammatory drugs (NSAIDs). This is an update of a review first published in 2002 (search date October 11, 2012). To assess the benefits and harms of topical and oral NSAIDs for treating people with lateral elbow pain. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE and SciSearch up to October 11, 2012. No language restriction was applied. Studies were included if they were randomised or quasi-randomised controlled trials (RCTs or CCTs) that compared topical or oral NSAIDs with placebo or another intervention, or compared two NSAIDs in adults with lateral elbow pain. Outcomes of interest were pain, function, quality of life, pain-free grip strength, overall treatment success, work loss and adverse effects. Two review authors independently selected the studies for inclusion, extracted the data, and performed a risk of bias assessment. Fifteen trials, involving 759 participants and reporting 17 comparisons, were included in the review. Four new trials identified from the updated search were included, along with 11 of 14 trials included in the original review (three trials included in the previous review were found not to meet inclusion criteria). Of eight trials that studied topical NSAIDs (301 participants), five compared topical NSAIDs with placebo, one compared manipulative therapy and topical NSAIDs with manipulative therapy alone, one compared leech therapy with topical NSAIDs and one compared two different topical NSAIDs. Of seven trials that investigated oral NSAIDs (437 participants), two compared oral NSAIDs with placebo, one compared oral NSAIDs and bandaging with bandaging alone, three compared oral NSAIDs with glucocorticoid injection, one compared oral NSAIDs with a vasodilator and two compared two different oral NSAIDs. No trials directly compared topical NSAIDs with oral NSAIDs. Few trials used intention-to-treat analysis, and the sample size of most was small. The median follow-up was 2 weeks (range 1 week to 1 year).Low-quality evidence was obtained from three trials (153 participants) suggesting that topical NSAIDs were significantly more effective than placebo with respect to pain in the short term (mean difference -1.64, 95% confidence interval (CI) -2.42 to -0.86) and number needed to treat to benefit (7 (95% CI 3 to 21) on a 0 to 10 scale). Low-quality evidence was obtained from one trial (85 participants) indicating that significantly more participants report fair, good or excellent effectiveness with topical NSAIDs versus placebo at 28 days (14 days of therapy) (risk ratio (RR) 1.49, 95% CI 1.04 to 2.14). No participants withdrew as the result of adverse events, but some studies reported mild adverse effects such as rash in 2.5% of those exposed to topical NSAIDs compared with 1.3% of those exposed to placebo.Low-quality and conflicting evidence regarding the benefits of oral NSAIDs obtained from two trials could not be pooled. One trial found significantly greater improvement in pain compared with placebo, and the other trial found no between-group differences; neither trial found differences in function. One trial reported a withdrawal due to adverse effects for a participant in the NSAIDs group. Use of oral NSAIDs was associated with increased risk of gastrointestinal side effects compared with placebo in one trial in the review. Another trial reported discontinuation of treatment due to gastrointestinal side effects in four participants taking NSAIDs, and another participant developed an allergic reaction in response to oral NSAIDs.Very scant and conflicting evidence regarding the comparative effects of oral NSAIDs and glucocorticoid injection was obtained. One trial reported a significant improvement in pain with glucocorticoid injection, and another found no between-group differences; treatment success was similar between groups (RR of fair, good or excellent effectiveness 0.74; 95% CI 0.43 to 1.26). Transient pain may occur following injection. There remains limited evidence from which to draw firm conclusions about the benefits or harms of topical or oral NSAIDs in treating lateral elbow pain. Although data from five placebo-controlled trials suggest that topical NSAIDs may be beneficial in improving pain (for up to 4 weeks), non-normal distribution of data and other methodological issues precluded firm conclusions. Some people may expect a mild transient skin rash. Evidence about the benefits of oral NSAIDs has been conflicting, although oral NSAID use may result in gastrointestinal adverse effects in some people. No direct comparisons between oral and topical NSAIDs were available. Some trials demonstrated greater benefit from glucocorticoid injection than from NSAIDs in the short term, but this was not apparent in all studies and was not apparent by 6 months in the only study that included longer-term outcomes.

Effectiveness and Safety of Topical versus Oral Nonsteroidal Anti-inflammatory Drugs: A Comprehensive Review

Introduction: Topical nonsteroidal anti-inflammatory drugs (NSAIDs) represent a relatively recent alternative to oral NSAIDs. Topical NSAIDs are designed to target their therapeutic effect locally to damaged tissue while minimizing systemic exposure. To better inform patients considering topical NSAIDs as an alternative to oral NSAIDs, this is the first comprehensive review to present all available evidence comparing topical NSAIDs with oral NSAIDs in the treatment of both acute and chronic musculoskeletal injury. Methods: Six studies, including 600 subjects, compared the use of topical versus oral NSAIDs in the treatment of a variety of acute injuries. Nine trials, including 2403 subjects, studied topical versus oral NSAIDs for chronic injury treatment, almost exclusively for osteoarthritis (OA) of the knee. This review included all available comparative studies, the majority of which were well-designed, double-dummy, placebo-controlled trials. Relevant meta-analyses were also reviewed. Results: Topical and oral NSAIDs performed statistically better than placebo for chronic injury treatment. Limited evidence comparing topical NSAIDs with placebo for acute injury treatment was available in the included studies, but supported greater effectiveness for topical NSAIDs. In all head-to-head comparisons, topical and oral NSAIDs demonstrated similar efficacy for treatment of both acute and chronic injuries. There were more gastrointestinal side effects in patients receiving oral NSAIDs, while local skin reactions occurred more frequently in patients treated with topical NSAIDs. Conclusion: Overall, topical NSAIDs may be considered as comparable alternatives to oral NSAIDs and are associated with fewer serious adverse events (specifically GI reactions) when compared with oral NSAIDs. Caution should be exercised with the use of both topical and oral NSAIDs, including close adherence to dosing regimens and monitoring, particularly for patients with previous adverse reactions to NSAIDs.

Topical Diclofenac Treatment for Post-Incisional Neuropathic Pain

Dear Editor, Neuropathic incisional pain is difficult to treat effectively and is probably mechanistically due to microneuroma formation and sensitization at the site of the incision. First-line pharmacological treatments for neuropathic pain include selective serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants calcium channel α2δ-subunit ligands (gabapentin and pregabalin), and topical lidocaine. The role of nonsteroidal anti-inflammatory drugs (NSAIDs) in treating neuropathic pain is unclear. Application of topical NSAIDs in the peripheral tissue is demonstrated to be efficacious in the treatment of acute and chronic nociceptive pain. NSAIDs may decrease inflammation of the peripheral nerves and the supporting structures that can cause neuropathic pain. Even so, NSAIDs are excluded from most treatment guidelines for any role in treating neuropathic pain, although a significant number of patients with neuropathic pain receive prescriptions for NSAIDs. We report a case of headaches and incisional pain treated with topical NSAID. To our knowledge, this is the first reported case of incisional pain treated with topical diclofenac plus dimethyl sulfoxide (DMSO). A 46-year-old gentleman with …

Osteoarthritis guidelines: a progressive role for topical nonsteroidal anti-inflammatory drugs

Current treatment guidelines for the treatment of chronic pain associated with osteoarthritis reflect the collective clinical knowledge of international experts in weighing the benefits of pharmacologic therapy options while striving to minimize the negative effects associated with them. Consideration of disease progression, pattern of flares, level of functional impairment or disability, response to treatment, coexisting conditions such as cardiovascular disease or gastrointestinal disorders, and concomitant prescription medication use should be considered when creating a therapeutic plan for a patient with osteoarthritis. Although topical nonsteroidal anti-inflammatory drugs historically have not been prevalent in many of the guidelines for osteoarthritis treatment, recent evidence-based medicine and new guidelines now support their use as a viable option for the clinician seeking alternatives to typical oral formulations. This article provides a qualitative review of these treatment guidelines and the emerging role of topical nonsteroidal anti-inflammatory drugs as a therapy option for patients with localized symptoms of osteoarthritis who may be at risk for oral nonsteroidal anti-inflammatory drug-related serious adverse events.

Use of drug combinations in patients with osteoarthritis: a population-based cohort study

Background Patients with osteoarthritis (OA) use different drugs in search for relief, with potential impact on both safety and costs. There is a scarcity of data on drug utilization in these patients. Objectives We used a large database including primary care medical records and pharmacy invoice data to explore use of the following drugs in OA patients in the period 2006-2010: non-steroidal anti-inflammatory drugs (NSAIDs), Symptomatic Slow Acting Drugs for OA (SYSADOA), COX-2 inhibitors (COX2i), opioids, and other analgesics (paracetamol and metamizol). Methods SIDIAP contains anonymised clinical information from primary care records and pharmacy invoice data for a representative >5 million people in Catalonia (North-East Spain). We screened this database (www.sidiap.org) to identify those aged 40 years or older with a new diagnosis of OA using ICD-10 codes. Among these, we ascertained prevalence of use of oral NSAIDs, COX2i, SYSADOA, opioids, and analgesics (all alone and in combination) in the period 2006-2011. We estimated prevalence (and 99% Confidence Intervals) of use of these drugs and their combinations, and the proportion of occasional (MPR≥25%) and regular (MPR≥50%) users for each of them. Results We identified 281,356 patients with an incident clinical diagnosis of OA. Among these, 128,314(45.6%) were treated with 3 or more drugs, and 57,835(20.6%) with none of the drugs studied. The 3 most common combinations of two drugs were: oral NSAID+analgesic (12.2%); 2.topical NSAID+analgesic (2.5%); and oral NSAID+SYSADOA (1.8%). Besides, 34,672(12.3%) patients received only 1 drug, the 3 most common being, in descending order: oral NSAID, analgesics, and SYSADOA. The proportions of occasional and regular users were highest for SYSADOA (24.5% occasional and 6.9% regular users), and lowest for opioids (7.3% occasional and 1.9% regular users). Conclusions About 75% of OA patients are treated with at least 2 drugs, and above half of them with 3 or more. However, compliance with these drugs is very low, and hence both clinical benefits and safety issues are difficult to predict using data from clinical trials, where compliance is high. These data are of interest for health care provision and clinical management of patients with OA. Disclosure of Interest D. Prieto-Alhambra Grant/research support from: Unrestricted grant from BIOIBERICA SA, N. Wilson: None Declared

Long-term effects of video-based home exercise on clinical and radiographic outcomes in subject with knee osteoarthritis: a two-year randomized controlled trial

Long-term effects of video-based home exercise on clinical and radiographic outcomes in subject with knee osteoarthritis: a two-year randomized controlled trial