What is the best nonsteroidal anti-inflammatory drug (NSAID) for osteoarthritis?

Best NSAID for Osteoarthritis

For osteoarthritis treatment, naproxen is generally the best NSAID option due to its favorable balance of efficacy and cardiovascular safety profile, though ibuprofen is the most cost-effective NSAID when paracetamol proves insufficient. 1, 2

Treatment Algorithm for Osteoarthritis

First-Line Treatment

1. Paracetamol (Acetaminophen)
   • Start with regular dosing up to 4g/day
   • Safest oral analgesic with acceptable efficacy
   • Monitor for adequate pain relief
   • Counsel patients to avoid other products containing paracetamol 1

Second-Line Treatment (If paracetamol inadequate)

1. Topical NSAIDs (especially for knee or hand OA)

   • Consider before oral NSAIDs
   • Particularly for localized pain
   • Especially recommended for patients ≥75 years 1

2. Oral NSAIDs - Preferred Options:

   • Ibuprofen (1.2g daily maximum)

     • Most cost-effective NSAID
     • Better safety profile than many other NSAIDs
     • Lower GI risk than diclofenac 1

   • Naproxen (up to 1000mg daily)

     • Better cardiovascular safety profile
     • Effective for pain relief and function improvement
     • Demonstrated efficacy in clinical trials 3, 2

NSAID Selection Considerations

Patient Risk Factors

• Cardiovascular risk:

  • Naproxen preferred (lower CV risk than other NSAIDs)
  • Avoid diclofenac (higher CV risk)
  • Use lowest effective dose for shortest duration 1, 2

• Gastrointestinal risk:

  • For high-risk patients: Add proton pump inhibitor (PPI) with traditional NSAIDs
  • Consider COX-2 inhibitor + PPI for highest risk patients
  • Celecoxib has lower GI risk than naproxen/diclofenac 4

• Age considerations:

  • For patients ≥75 years: Topical NSAIDs strongly preferred over oral 1
  • For older patients who need oral NSAIDs: Lower doses (e.g., naproxen 440mg/day for ≥65 years) 5

Evidence for NSAID Efficacy in OA

• NSAIDs are more effective than placebo for OA pain (ES median 0.49) 1
• Naproxen showed greater pain reduction than paracetamol (ES 0.32 after 42 days, 0.45 after 730 days) 1
• Celecoxib demonstrated similar efficacy to naproxen and diclofenac but with fewer GI events 4
• Non-prescription doses of naproxen sodium (660mg/day for <65 years; 440mg/day for ≥65 years) showed significant improvements in pain and function over 7 days 5

Common Pitfalls and Caveats

1. Prolonged NSAID use:

   • Review NSAID requirements regularly (at least every 6 months)
   • Encourage "as needed" rather than continuous use 1

2. Inappropriate risk assessment:

   • Always assess GI, CV, and renal risk factors before prescribing
   • Consider individual patient comorbidities and concomitant medications

3. Inadequate gastroprotection:

   • Add PPI when prescribing NSAIDs to high-risk patients
   • Don't assume all NSAIDs carry equal GI risk

4. Overlooking non-pharmacological approaches:

   • Exercise therapy has similar effects on pain and function as NSAIDs/paracetamol with better safety profile 1
   • Always combine NSAID therapy with core treatments (exercise, weight loss if overweight) 1

5. Failure to adjust dosing for elderly:

   • Lower doses for patients ≥65 years
   • Consider topical NSAIDs first for patients ≥75 years 1

Remember that while NSAIDs are effective for OA pain, they should be used at the lowest effective dose for the shortest duration possible to minimize adverse effects. Regular reassessment of the need for continued NSAID therapy is essential.