What is the recommended pain management strategy for a patient with osteoarthritis who has experienced a gastrointestinal (GI) bleed?

From the Guidelines

For patients with osteoarthritis who have experienced a gastrointestinal bleed, acetaminophen is the first-line medication, and topical NSAIDs like diclofenac gel 1% can provide localized relief without significant systemic absorption. The recommended pain management strategy should prioritize safety while providing effective relief, considering the patient's history of GI bleed. According to the most recent and highest quality study 1, oral nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen have been widely adopted in the treatment of knee osteoarthritis, but it is essential to understand the appropriate prescribing for these medications due to their potential risks.

Some key points to consider in the management of osteoarthritis with a history of GI bleed include:

• Starting with acetaminophen at 500-1000 mg every 6 hours with a maximum daily dose of 3000 mg
• Using topical NSAIDs like diclofenac gel 1% applied to the affected joint 4 times daily for localized relief
• Considering non-pharmacological approaches such as physical therapy, weight management, assistive devices, and activity modification
• If traditional NSAIDs are necessary, using them at the lowest effective dose for the shortest duration possible with concurrent proton pump inhibitor therapy, such as omeprazole 20 mg daily
• Avoiding oral narcotics, including tramadol, due to the notable increase in medication-related adverse effects with no consistent improvement in pain and function, as recommended by the 2022 study 1.

It is crucial to balance pain relief while minimizing the risk of recurrent GI bleeding, particularly since traditional NSAIDs can damage the GI mucosa and impair platelet function, potentially exacerbating bleeding risks. The 2008 study 1 also supports the use of acetaminophen and topical NSAIDs as first-line treatments, emphasizing the importance of using oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible period of time, alongside a proton pump inhibitor.

From the FDA Drug Label

Strategies to Minimize the GI Risks in NSAID-treated patients: • Use the lowest effective dosage for the shortest possible duration. • Avoid administration of more than one NSAID at a time. • Avoid use in patients at higher risk unless benefits are expected to outweigh the increased risk of bleeding For such patients, as well as those with active GI bleeding, consider alternate therapies other than NSAIDs.

The recommended pain management strategy for a patient with osteoarthritis who has experienced a gastrointestinal (GI) bleed is to consider alternate therapies other than NSAIDs.

• Avoid NSAIDs in patients with a history of GI bleeding unless the benefits outweigh the increased risk of bleeding.
• Monitor patients closely for signs and symptoms of GI ulceration and bleeding during NSAID therapy, if NSAIDs are used. 2

From the Research

Pain Management Strategies for Osteoarthritis with GI Bleed

• The use of cyclo-oxygenase-2 (COX-2) selective inhibitors, such as celecoxib, is recommended for patients with osteoarthritis who are at high risk of gastrointestinal (GI) events, including those with a history of GI bleed 3, 4, 5.
• Celecoxib has been shown to be effective in reducing the signs and symptoms of osteoarthritis, while also reducing the risk of GI ulcers and bleeding compared to non-selective NSAIDs 3, 4, 5.
• The addition of a proton pump inhibitor (PPI) to celecoxib or a non-selective NSAID can further reduce the risk of GI bleeding and is considered a cost-effective option 6, 4.
• Patients with osteoarthritis who have experienced a GI bleed should be treated with a COX-2 inhibitor, such as celecoxib, plus a PPI, rather than a non-selective NSAID, to minimize the risk of recurrent GI bleeding 4.
• The choice of pain management strategy should take into account the individual patient's cardiovascular and gastrointestinal risks, as well as their medical history and current medications 3, 6, 4, 7.

Considerations for Treatment

• The use of celecoxib and other COX-2 inhibitors should be weighed against the potential benefits and risks, including the risk of cardiovascular events 3, 4, 5.
• Patients with a history of GI bleed should be closely monitored for signs of recurrent bleeding and should receive regular follow-up care to minimize the risk of complications 4.
• The use of PPIs should be optimized to minimize the risk of GI bleeding and to reduce the risk of adverse events, such as osteoporosis and pneumonia 6, 4.