Management of Osteoarthritis: Expert Opinion on NSAIDs

Abstract

Osteoarthritis (OA) is a leading cause of disability among older adults worldwide. Treatment aims are to alleviate inflammatory pain and improve physical function through non-pharmacological and pharmacological interventions. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy. However, selection is challenged by patient age, comorbidities and polypharmacy, and by the drug's benefit/risk balance, all of which together influence the risk of cardiovascular (CV), gastrointestinal (GI) and renal adverse events (AEs). While the efficacy profile of the various NSAIDs is delineated, the differences in their safety profile are not straightforward. This narrative review provides practical indications by a multidisciplinary Italian expert panel for general practitioners and specialists managing OA patients with chronic inflammatory pain; the goal is to maximize therapy efficacy while reducing untoward effects caused by inappropriate NSAID use. The discussion on the best approach to NSAIDs spanned the following topics: (1) patient evaluation: investigate pain origin, duration and components together with possible risk factors for CV, GI and renal AEs; (2) non-pharmacological interventions: the physiatrist provides a person-centered, holistic approach accounting for all patient aspects; (3) pharmacological interventions: patient profile and drugs' pharmacological properties affect NSAID selection, which drugs to be used in combination or to be avoided, formulation and therapy duration; (4) the pharmacologist's, general practitioner's and pain therapist's points of view; (5) NSAID safety: the individual baseline risk and the drug's safety profile are major determinants of CV, GI and renal risk; consider possible drug-drug interactions; (6) periodical re-evaluation of treatment response and adherence, using scales to assess pain and function.

Keywords: Chronic inflammatory pain; Clinical practice; Non-steroidal anti-inflammatory drugs; Osteoarthritis; Safety.

Fig. 1

The ideal pathway for osteoarthritis patients suffering from chronic inflammatory pain. GP General practitioner, NSAIDs non-steroidal anti-inflammatory drugs

Fig. 2

The main adverse events observed in osteoarthritis patients upon NSAID therapy (see text for discussion). AKI Acute kidney injury, AMI acute myocardial infarction, CKD chronic kidney disease, COX cyclooxygenase, coxibs COX-2 inhibitors, CV cardiovascular, GFR glomerular filtration rate, GI gastrointestinal, tNSAIDs traditional non-steroidal anti-inflammatory drugs, TXA2 thromboxane A2