What are the treatment options for a patient with osteoarthritis (Nonsteroidal Anti-Inflammatory Drugs (NSAIDs))?

Osteoarthritis Pain Treatment with NSAIDs

For osteoarthritis pain, oral NSAIDs are strongly recommended when acetaminophen and topical NSAIDs fail, but must be prescribed at the lowest effective dose for the shortest duration alongside mandatory proton pump inhibitor gastroprotection. 1

Treatment Algorithm

Step 1: Core Non-Pharmacological Treatments (Essential for All Patients)

• Exercise and physical activity including local muscle strengthening and general aerobic fitness are mandatory foundational treatments that must accompany any pharmacological intervention 1
• Weight loss interventions if the patient is overweight or obese to reduce mechanical joint stress 1
• Patient education to counter the misconception that osteoarthritis is inevitably progressive and untreatable 1

Step 2: First-Line Pharmacological Treatment

• Start with acetaminophen at regular doses up to 4000 mg daily (consider maximum 3000 mg daily in elderly patients for enhanced safety) 1, 2
• For knee and hand osteoarthritis specifically, try topical NSAIDs (such as diclofenac gel) before oral NSAIDs due to minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications 1

Step 3: When to Escalate to Oral NSAIDs

Oral NSAIDs are indicated when:

• Acetaminophen at full dose provides insufficient pain relief 1
• Topical NSAIDs have failed (for knee/hand OA) 1
• The patient has no contraindications to NSAID use 1

Step 4: Oral NSAID Prescribing Protocol

Selection and Dosing:

• Choose either a COX-2 selective inhibitor (other than etoricoxib 60 mg) or a standard NSAID as first choice 1
• All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but differ in gastrointestinal, hepatic, and cardiorenal toxicity profiles 1
• Use the lowest effective dose for the shortest possible duration 1

Mandatory Gastroprotection:

• Always co-prescribe a proton pump inhibitor alongside any oral NSAID or COX-2 inhibitor, selecting the one with lowest acquisition cost 1, 3

Risk Assessment Before Prescribing:

• Assess cardiovascular risk factors (hypertension, heart disease, heart failure) 1, 2
• Assess gastrointestinal bleeding risk (history of ulcers, age >75 years, concurrent anticoagulants or corticosteroids) 1, 4
• Assess renal function (chronic kidney disease) 1
• Consider age as a major risk factor—elderly patients face substantially higher risks 1, 2

Step 5: Special Populations and Situations

Patients Age ≥75 Years:

• Strongly prefer topical NSAIDs over oral NSAIDs due to significantly lower systemic toxicity risk 1

Patients with History of Upper GI Ulcer (No Bleed in Past Year):

• If oral NSAID is chosen, use either a COX-2 selective inhibitor OR a nonselective NSAID, both combined with a proton pump inhibitor 1

Patients with Upper GI Bleed Within Past Year:

• If oral NSAID is still chosen, use a COX-2 selective inhibitor combined with a proton pump inhibitor 1

Patients Taking Low-Dose Aspirin:

• Consider other analgesics before adding an NSAID or COX-2 inhibitor (plus proton pump inhibitor) 1

Step 6: Alternative Options When NSAIDs Insufficient or Contraindicated

• Tramadol can be added or substituted, though the 2022 AAOS guideline notes tramadol results in notable adverse events without improving pain or function 1
• Intra-articular corticosteroid injections for moderate to severe pain, particularly with joint effusion 1
• Duloxetine as a conditional recommendation 1
• Topical capsaicin for knee osteoarthritis 1

Critical Safety Warnings

Cardiovascular Risks:

• NSAIDs increase risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal 4
• Risk increases with longer use and in patients with cardiovascular disease 4
• Never use NSAIDs immediately before or after coronary artery bypass graft (CABG) surgery 4

Gastrointestinal Risks:

• NSAIDs cause ulcers and bleeding in the stomach and intestines at any time during treatment 4
• Ulcers and bleeding can occur without warning symptoms and may cause death 4
• Risk increases with: corticosteroids, anticoagulants, longer use, smoking, alcohol, older age, and poor health 4

Renal Risks:

• Monitor renal function, particularly in elderly patients and those with pre-existing renal impairment 1

Common Pitfalls to Avoid

• Never prescribe oral NSAIDs without proton pump inhibitor co-prescription—this is mandatory gastroprotection 1, 3
• Do not use glucosamine or chondroitin products—current evidence does not support their efficacy 1, 3
• Avoid prolonged high-dose NSAID use, especially in elderly patients who are at highest risk for serious adverse events 1, 2
• Do not skip the core non-pharmacological treatments—exercise, weight loss, and education are essential components that improve outcomes 1
• Do not use NSAIDs in combination with aspirin for OA—aspirin increases naproxen excretion and the combination results in higher adverse event frequency without additional benefit 4

Monitoring Requirements

• Assess individual risk factors including age before initiating NSAIDs 1
• Consider ongoing monitoring of gastrointestinal, hepatic, and renal function during NSAID therapy 1
• Periodic review tailored to individual needs to reassess treatment effectiveness and safety 1