How to manage severe osteoarthritis in a patient on Brilinta (ticagrelor), an antiplatelet medication?

Managing Severe Osteoarthritis in Patients on Brilinta (Ticagrelor)

For patients on Brilinta with severe osteoarthritis, avoid all oral NSAIDs due to significantly increased bleeding risk, and instead prioritize acetaminophen, topical NSAIDs, exercise therapy, weight loss if overweight, and intra-articular corticosteroid injections, with joint replacement surgery considered when conservative measures fail. 1, 2

Critical Safety Consideration: Antiplatelet Therapy and Bleeding Risk

The most important clinical decision point is avoiding oral NSAIDs entirely in patients on ticagrelor (Brilinta). 3

• Ticagrelor is a potent antiplatelet agent that interferes with hemostasis, and when combined with NSAIDs, creates a synergistic effect on bleeding risk that is substantially higher than either drug alone 3
• The FDA explicitly warns that concomitant use of antiplatelet drugs with NSAIDs requires close monitoring for signs of bleeding, though monitoring does not eliminate the risk 3
• The safest approach is complete avoidance of oral NSAIDs (including ibuprofen, naproxen, meloxicam, and celecoxib) rather than attempting to use them with monitoring 1, 3

Recommended Treatment Algorithm

First-Line Pharmacological Options (Safest with Antiplatelet Therapy)

Acetaminophen (Paracetamol):

• Use as the primary oral analgesic at regular dosing up to 4,000 mg/day in divided doses 2
• This is the safest systemic medication for patients on antiplatelet therapy as it does not affect hemostasis 1
• Monitor for hepatotoxicity, particularly if the patient has liver disease or uses alcohol 2

Topical NSAIDs:

• Strongly recommended as the preferred NSAID option for knee and hand osteoarthritis due to minimal systemic absorption and negligible bleeding risk 2
• Apply to affected joints 3-4 times daily 1
• Provides localized pain relief without the systemic hemostatic effects that create bleeding risk with oral NSAIDs 2

Core Non-Pharmacological Treatments (Strongly Recommended)

Exercise Therapy:

• Strongly recommended for all patients with hip, knee, or hand osteoarthritis 1
• Include strengthening exercises for muscles around affected joints, low-impact aerobic activities (walking, swimming, cycling), and range of motion exercises 1
• Aim for at least 30 minutes most days of the week 2
• Referral to physical therapy is beneficial for proper instruction and maintenance of exercise programs 1

Weight Loss (if overweight/obese):

• Strongly recommended as even 5-10% body weight reduction significantly reduces mechanical stress on weight-bearing joints and improves pain 1, 2

Patient Education:

• Essential to counter misconceptions about osteoarthritis and improve treatment adherence 2
• Discuss activity pacing, joint protection strategies, and realistic expectations 1

Second-Line Options When First-Line Measures Are Insufficient

Intra-articular Corticosteroid Injections:

• Recommended for moderate to severe pain flares, particularly effective for knee and hip osteoarthritis 2
• Provides temporary relief (typically weeks to months) without systemic bleeding risk 1
• Can be repeated periodically as needed 2

Intra-articular Hyaluronic Acid (Viscosupplementation):

• Conditionally recommended for knee osteoarthritis when other treatments fail 1
• May provide longer-lasting relief than corticosteroid injections in some patients 2

Adjunctive Physical Modalities

• Local heat or cold applications for temporary pain relief 2
• Transcutaneous electrical nerve stimulation (TENS) for pain management 2
• Assistive devices (canes, walkers, braces) to reduce joint load and improve function 2
• Manual therapy through physical therapy referral 1

Surgical Consideration

Joint Replacement Surgery:

• Refer to orthopedic surgery when pain and functional limitation substantially affect quality of life despite comprehensive conservative treatment for 3-6 months 1, 2
• Surgery provides excellent results for severe osteoarthritis unresponsive to medical management 2
• The presence of antiplatelet therapy requires perioperative management but is not an absolute contraindication to surgery 1

Treatments NOT Recommended

• Oral NSAIDs (all types) due to bleeding risk with ticagrelor 3
• Glucosamine and chondroitin supplements (no significant benefit over placebo) 2
• Electroacupuncture (insufficient evidence) 2

Monitoring and Follow-Up

• Schedule regular follow-up at 6-12 weeks to assess treatment effectiveness and adjust therapy as needed 2
• Monitor for any signs of bleeding (bruising, gastrointestinal symptoms, unusual bleeding) given the antiplatelet therapy 3
• Reassess functional status and pain levels to determine if surgical referral is warranted 2