What is the best NSAID (Non-Steroidal Anti-Inflammatory Drug) for knee osteoarthritis?

From the Guidelines

Naproxen (250-500mg twice daily) is the most recommended NSAID for knee osteoarthritis due to its longer-lasting relief and lower risk of heart-related side effects compared to other NSAIDs. The choice of NSAID should be individualized, considering factors such as gastrointestinal risk, cardiovascular concerns, and patient tolerance 1. According to the EULAR recommendations, NSAIDs should be considered in patients unresponsive to paracetamol, and in patients with an increased gastrointestinal risk, non-selective NSAIDs and effective gastroprotective agents, or selective COX 2 inhibitors should be used 1. Some key points to consider when prescribing NSAIDs for knee osteoarthritis include:

• Starting with the lowest effective dose and taking with food to minimize gastrointestinal side effects
• Monitoring long-term use due to potential kidney, cardiovascular, and gastrointestinal risks
• Considering intermittent use during pain flares rather than continuous use
• Combining NSAIDs with non-pharmacological approaches like weight management and physical therapy for comprehensive osteoarthritis management
• Alternatives like celecoxib (100-200mg daily) may be considered for patients with higher gastrointestinal risk, but may be more costly. It's essential to weigh the benefits and risks of NSAID use in individual patients, taking into account their unique medical history, comorbidities, and lifestyle factors 1.

From the FDA Drug Label

Gastrointestinal Bleeding, Ulceration, and Perforation NSAIDs, including diclofenac, cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the esophagus, stomach, small intestine, or large intestine, which can be fatal.

The FDA drug label does not answer the question.

From the Research

NSAID Options for Knee Osteoarthritis

• Naproxen sodium has been shown to be effective in managing moderate osteoarthritis of the knee, with significant improvements in pain and physical function compared to placebo 2, 3.
• Ibuprofen is also effective in relieving pain in patients with mild to moderate osteoarthritis of the knee, although naproxen sodium may provide more effective pain relief for most variables 3.
• Etodolac has been found to be as effective and safe as naproxen in the management of osteoarthritis of the knee 4.
• Diclofenac sodium has been shown to be effective in the symptomatic treatment of osteoarthritis of the knee, while acetaminophen is not 5.
• Intraarticular sodium hyaluronate (Hyalgan) has been found to be generally well tolerated and provides sustained relief of pain and improved patient function, with at least as much effectiveness and fewer adverse reactions as continuous treatment with naproxen 6.

Comparison of NSAIDs

• Naproxen sodium and ibuprofen have been compared in terms of their analgesic efficacy and safety, with both being effective in relieving pain in patients with osteoarthritis of the knee 3.
• Etodolac and naproxen have been compared, with both being found to be effective and safe in the management of osteoarthritis of the knee 4.
• Diclofenac sodium and acetaminophen have been compared, with diclofenac being found to be effective in the symptomatic treatment of osteoarthritis of the knee, while acetaminophen is not 5.
• Intraarticular sodium hyaluronate (Hyalgan) has been compared to naproxen, with Hyalgan being found to be at least as effective with fewer adverse reactions 6.

Safety and Tolerability

• Naproxen sodium has been found to be well tolerated, with no significant differences in adverse events between groups, regardless of age 2.
• Ibuprofen has been found to be effective and safe in relieving pain in patients with osteoarthritis of the knee, with no significant differences in adverse event reporting between groups 3.
• Etodolac has been found to be safe, with no significant between-group differences in the numbers of patients who had an adverse experience, a serious adverse experience, or an adverse experience leading to study discontinuation 4.
• Diclofenac sodium has been found to be effective, but acetaminophen is not, and naproxen has been found to have fewer adverse reactions than diclofenac sodium 5, 6.