What is the best approach to manage severe bilateral knee pain unresponsive to meloxicam (Nonsteroidal Anti-Inflammatory Drug (NSAID)) and currently managed with Alleve (Naproxen)?

From the Guidelines

For severe bilateral knee pain unresponsive to meloxicam and currently managed with naproxen (Aleve), I strongly recommend a multimodal approach prioritizing non-pharmacological interventions and considering alternative pharmacological options. This approach is based on the most recent and highest quality evidence available, including the 2020 US Department of Veterans Affairs/US Department of Defense clinical practice guideline for the non-surgical management of hip and knee osteoarthritis 1. The key components of this approach include:

• Discussing a self-management program with the patient, focusing on regular self-directed exercise and comprehensive lifestyle intervention for weight reduction if applicable.
• Considering referral for physical therapy to improve functional limitations and adherence to the treatment plan.
• Using topical agents for OA of the knee, such as NSAIDs and capsaicin, as initial pharmacotherapy.
• Offering acetaminophen and/or oral NSAIDs for pain associated with OA of the hip and knee, with the understanding that NSAIDs have exhibited superiority to acetaminophen in those with moderate-to-severe OA pain 1.
• Considering the use of duloxetine, a selective serotonin and norepinephrine reuptake inhibitor, for patients with OA, as it has been shown to achieve significant reductions in pain outcomes and improvement in physical function 1. Some important points to consider:
• The patient should be educated on the proper use of duloxetine, including taking it daily and not discontinuing it without consultation with their prescribing provider.
• Opioids, including tramadol, are not recommended for managing OA pain due to their limited benefit and high risk of adverse effects 1.
• Weight management is crucial, as each pound lost reduces knee pressure by four pounds.
• For immediate relief, consider knee braces for stability and ice therapy (20 minutes on, 20 minutes off) several times daily. If these conservative measures fail after 4-6 weeks, consulting with an orthopedic specialist about intra-articular corticosteroid injections or hyaluronic acid injections may be necessary. This comprehensive approach addresses pain through multiple mechanisms, minimizing reliance on a single NSAID that has proven ineffective, and targets both symptom management and potential underlying causes of knee pain.

From the Research

Management of Severe Bilateral Knee Pain

The patient's complaint of 10 out of 10 bilateral knee pain, unresponsive to meloxicam and currently managed with Alleve (Naproxen), suggests a need for alternative management strategies.

• Assessment and Diagnosis: A comprehensive assessment is necessary to determine the underlying cause of the knee pain, which could be due to osteoarthritis (OA), patellofemoral pain, or meniscal tears 2.
• Treatment Options: For OA, first-line management includes exercise therapy, weight loss (if overweight), education, and self-management programs 2. Intra-articular injections of corticosteroids and radiofrequency ablation of the genicular nerves have been shown to be effective for chronic knee pain 3.
• Pharmacological Interventions: Tramadol, an analgesic, has been studied as an alternative to NSAIDs for OA management. Moderate quality evidence suggests that tramadol alone or in combination with acetaminophen has no important benefit on mean pain or function in people with OA, although slightly more people in the tramadol group report an important improvement 4, 5.
• Considerations for Severe Bilateral Knee Pain: The influence of pain on knee joint movement and moment during the stance phase should be considered, as strong pain may contribute to decreased knee joint function 6.

Potential Next Steps

Based on the available evidence, potential next steps for managing the patient's severe bilateral knee pain could include:

• Re-evaluating the patient's diagnosis and underlying cause of knee pain
• Considering alternative pharmacological interventions, such as tramadol, under close monitoring for adverse events
• Exploring non-pharmacological interventions, such as exercise therapy, weight loss, and education
• Discussing the potential benefits and risks of intra-articular injections or radiofrequency ablation with the patient 3