What initial prescription will the healthcare provider likely add to the treatment regimen of a patient with osteoarthritis (OA) who has inadequate pain relief with physical therapy?

From the Guidelines

The healthcare provider will likely add acetaminophen to the patient's treatment regimen for osteoarthritis (OA) of the knee, as it is a recommended initial pharmacologic treatment for patients with inadequate pain relief with physical therapy. According to the most recent and highest quality study 1, acetaminophen is suggested as an initial treatment option for pain associated with OA of the hip and knee. The study recommends offering acetaminophen and/or oral NSAIDs for pain associated with OA, and acetaminophen is typically started at 325-650 mg every 4-6 hours as needed, not exceeding 3000 mg daily.

The choice between acetaminophen and NSAIDs depends on the patient's pain severity, inflammatory component, comorbidities, and risk factors. NSAIDs may be more effective when inflammation is present but carry risks of gastrointestinal, cardiovascular, and renal side effects, particularly with prolonged use. For patients with risk factors for these complications, acetaminophen may be safer as the initial choice. Other options like duloxetine 1 and topical capsaicin may be considered for patients who do not respond to initial treatments, but acetaminophen is a more appropriate initial choice. Opioids, including tramadol, are not recommended for the management of OA pain due to limited benefit and high risk of adverse effects 1.

Some key points to consider when prescribing acetaminophen for OA include:

• Starting dose: 325-650 mg every 4-6 hours as needed
• Maximum daily dose: 3000 mg
• Potential side effects: liver damage with excessive use
• Considerations: patient's pain severity, inflammatory component, comorbidities, and risk factors.

It's essential to weigh the benefits and risks of each treatment option and consider the individual patient's needs and preferences when making a decision.

From the FDA Drug Label

In the pooled population, 66%, 61%, 61%, 43%, and 94% of adult patients were female; and 82%, 73%, 85%, 74%, and 86% of adult patients were Caucasian in the MDD, GAD, OA and CLBP, DPNP, and FM populations, respectively. Most patients received duloxetine delayed-release capsules dosages of a total of 60 to 120 mg per day [see CLINICAL STUDIES (14)]

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).

The healthcare provider will likely add duloxetine to the patient's treatment regimen, as it has been shown to be effective in the treatment of chronic pain due to osteoarthritis (OA) in adults, with a recommended dosage of 60 to 120 mg per day 2.

• Key points:
  • Duloxetine has been established as an effective treatment for OA in adults.
  • The recommended dosage is 60 to 120 mg per day.
  • Duloxetine has been shown to provide significant pain reduction in patients with OA.
• Note: The information provided is based on the drug label for duloxetine, which includes data from clinical trials assessing its efficacy in treating OA 2 2.

From the Research

Treatment Options for Osteoarthritis

The healthcare provider may consider adding the following medications to the patient's treatment regimen:

• Acetaminophen: a common analgesic for pain management, although its efficacy in osteoarthritis is controversial 3
• Duloxetine: an antidepressant that can be used for chronic pain management, but its use in osteoarthritis is not as well-established as other options
• Tramadol: an opioid analgesic that has been shown to provide some pain relief in osteoarthritis, but with a higher risk of adverse events 4, 5
• Capsaicin cream: a topical analgesic that may provide some pain relief, but its effectiveness in osteoarthritis is not as well-studied as other options

Efficacy of Tramadol in Osteoarthritis

Studies have shown that tramadol can provide some pain relief in osteoarthritis, but its effectiveness is moderate at best 4, 5. The addition of acetaminophen to tramadol may not significantly improve pain relief 4, 6.

Comparison of Treatment Options

The choice of medication will depend on the patient's individual needs and medical history. The healthcare provider will need to weigh the potential benefits and risks of each medication, including the risk of adverse events and interactions with other medications. According to the studies, tramadol alone or in combination with acetaminophen probably has no important benefit on mean pain or function in people with osteoarthritis, although slightly more people in the tramadol group report an important improvement 4.