From the Guidelines
Treatment of osteoarthritis in patients with NSAID contraindications should prioritize non-pharmacological approaches, such as exercise, weight loss, and physical therapy, as well as alternative pharmacologic options like acetaminophen, tramadol, and duloxetine, as recommended by the 2019 American College of Rheumatology guideline 1. When managing osteoarthritis in patients who cannot use NSAIDs, it's crucial to consider the patient's overall health and the severity of their osteoarthritis.
- Non-pharmacological interventions are strongly recommended and include:
- Exercise, such as aerobic, aquatic, and/or resistance exercises, which can help improve joint mobility and reduce pain 1
- Weight loss for overweight or obese patients, as each pound lost reduces knee stress by four pounds
- Physical therapy focusing on strengthening exercises and assistive devices like braces or canes
- For patients requiring pharmacologic therapy, options include:
- Acetaminophen (Tylenol) at doses up to 3000 mg daily divided into 3-4 doses
- Tramadol (50-100 mg every 4-6 hours) or duloxetine (30-60 mg daily) for moderate to severe pain, as conditionally recommended by the 2019 guideline 1
- Intra-articular corticosteroid injections every 3-4 months, which can provide temporary pain relief
- Viscosupplementation with hyaluronic acid injections, although its effectiveness is still debated
- Non-pharmacological approaches like heat/cold therapy, acupuncture, and cognitive behavioral therapy can complement medical treatment and are conditionally recommended by the 2019 guideline 1.
- In advanced cases unresponsive to conservative measures, surgical interventions including joint replacement may be necessary, as a last resort to improve quality of life and reduce morbidity. The 2019 American College of Rheumatology guideline 1 provides the most recent and highest quality evidence for the management of osteoarthritis, and its recommendations should be prioritized when making treatment decisions.
From the FDA Drug Label
Trials in Chronic Pain Due to Osteoarthritis in Adults The efficacy of duloxetine delayed-release capsules in chronic pain due to osteoarthritis (OA) in adults was assessed in 2 double-blind, placebo-controlled, randomized clinical trials of 13-weeks duration (Study OA-1 and Study OA-2). All patients in both trials fulfilled the ACR clinical and radiographic criteria for classification of idiopathic OA of the knee. Randomization was stratified by the patients’ baseline NSAIDs-use status Patients assigned to duloxetine delayed-release capsules started treatment in both trials at a dose of 30 mg once daily for one week. After the first week, the dose of duloxetine delayed-release capsules was increased to 60 mg once daily After 7 weeks of treatment with duloxetine delayed-release capsules 60 mg once daily, in Study OA-1 patients with sub-optimal response to treatment (<30% pain reduction) and tolerated duloxetine delayed-release capsules 60 mg once daily had their dose increased to 120 mg However, in Study OA-2, all patients, regardless of their response to treatment after 7 weeks, were re-randomized to either continue receiving duloxetine delayed-release capsules 60 mg once daily or have their dosage increased to 120 mg once daily for the remainder of the trial.
Treatment Options for Osteoarthritis without NSAIDs:
- Duloxetine delayed-release capsules can be used to treat chronic pain due to osteoarthritis in adults.
- The recommended dose is 30 mg once daily for one week, then increased to 60 mg once daily.
- If patients have a sub-optimal response to treatment, the dose can be increased to 120 mg once daily.
- Duloxetine delayed-release capsules have been shown to be effective in reducing pain in patients with osteoarthritis, even in those with a contraindication to NSAIDs 2.
From the Research
Treatment Options for Osteoarthritis without NSAIDs
In patients where Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are contraindicated, several alternative treatment options can be considered for managing osteoarthritis (OA). These include:
- Acetaminophen: As mentioned in 3, acetaminophen is a common pharmacologic treatment for OA, providing an alternative for pain management when NSAIDs cannot be used.
- Tramadol: Studies such as 4 and 5 have shown that tramadol can decrease pain intensity and improve function in patients with OA, although the benefits are small and it may come with adverse events.
- Intra-articular Corticosteroids: According to 6, intra-articular corticosteroid injections are generally recommended for OA management and have relatively minor adverse effects, making them a viable option.
- Intra-articular Hyaluronic Acid: Also mentioned in 6, intra-articular hyaluronic acid injections can be considered for the treatment of OA, especially in patients who cannot tolerate NSAIDs.
- Capsaicin: As noted in 6, capsaicin is another treatment option, although its use may be more controversial and guidelines may vary.
- Duloxetine: Listed in 6 as one of the pharmaceutical classes for OA treatment, duloxetine can be an option for managing OA pain, especially in patients with contraindications to NSAIDs.
Considerations for Treatment
When selecting a treatment option for a patient with a contraindication to NSAIDs, it is essential to consider the patient's specific parameters and comorbid conditions, as highlighted in 7. This includes evaluating the potential risks and benefits of each treatment option and discussing these with the patient to make an informed decision.
Alternatives and Complementary Therapies
Besides pharmacological treatments, non-pharmacological approaches such as physical therapy, lifestyle modifications, and complementary therapies can also play a crucial role in managing OA symptoms in patients who cannot use NSAIDs. However, the provided evidence does not directly discuss these alternatives in detail.