What alternative treatments can be given to a patient on Aspirin (acetylsalicylic acid) and Plavix (clopidogrel) for osteoarthritis (OA) of the hands if topical creams are ineffective?

From the Guidelines

For a patient with osteoarthritis (OA) of the hands who is on ASA (aspirin) and Plavix (clopidogrel) and hasn't responded to topical creams, I recommend acetaminophen (Tylenol) as the first-line oral medication, starting at 500-650mg every 6 hours as needed, not exceeding 3000mg daily. This recommendation is based on the 2019 American College of Rheumatology guideline for the management of osteoarthritis of the hand, hip, and knee 1. Acetaminophen is preferred because it doesn't increase bleeding risk like NSAIDs would in patients on dual antiplatelet therapy.

Some key points to consider when managing OA in patients on antiplatelet therapy include:

• The importance of a comprehensive approach to OA management, including physical, educational, behavioral, psychosocial, mind-body, and pharmacologic interventions 1
• The need to balance the benefits and risks of different treatment options, particularly in patients with comorbidities or on multiple medications 1
• The potential for non-pharmacological approaches, such as physical therapy or occupational therapy, to provide additional relief and improve quality of life

If acetaminophen provides insufficient relief, consider adding a non-pharmacological approach such as physical therapy, occupational therapy with splinting, or paraffin wax treatments. For more severe pain, tramadol 50mg every 6 hours as needed might be considered for short-term use, as suggested by the guideline 1. In some cases, if pain remains uncontrolled, consultation with the patient's cardiologist about temporarily modifying the antiplatelet regimen to allow for a short course of an NSAID might be warranted, though this carries increased cardiovascular and bleeding risks. Intra-articular corticosteroid injections can also provide temporary relief for specific painful joints without significantly affecting the antiplatelet therapy.

From the Research

Treatment Options for Osteoarthritis of the Hands

If creams have not been effective in managing osteoarthritis (OA) of the hands in a patient taking ASA and Plavix, there are several other treatment options to consider:

• Acetaminophen: This is a common pharmacologic treatment for OA, as discussed in 2.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): These can be used to alleviate symptoms of OA, but their use must be carefully considered in patients taking ASA and Plavix due to potential interactions and increased risk of cardiovascular disease, as noted in 3, 4, and 5.
• Nerve growth factor antibodies: These are a new class of agents under clinical investigation for the treatment of OA, as mentioned in 2.
• Alternative NSAIDs: Naproxen may be preferred over other NSAIDs due to its potential lower cardiovascular risk, as discussed in 3 and 5.
• Gastroprotective agents: These may be necessary to reduce the risk of gastrointestinal adverse events associated with NSAID use, as noted in 3 and 4.

Considerations for Patients Taking ASA and Plavix

When considering treatment options for OA in patients taking ASA and Plavix, it is essential to take into account the potential interactions and increased risk of cardiovascular disease:

• The risk of cardiovascular disease may be higher in patients taking naproxen or ibuprofen with low-dose aspirin, as found in 5.
• The use of NSAIDs, including naproxen and ibuprofen, may increase the risk of gastrointestinal adverse events, as discussed in 3 and 4.
• The effects of osteoarthritis and rheumatoid arthritis on fracture risk should also be considered, as noted in 6.