Because of cardiovascular and gastrointestinal risks, NSAIDS are no longer recommended for long-term use. No single drug or therapy is regarded as the ideal long-term treatment for osteoarthritis.
Nonsteroidal anti-inflammatory drugs (NSAIDs) have long been used to reduce pain and inflammation caused by osteoarthritis (OA). Until recently, these drugs were prescribed in fairly high doses and often for years, according to Steven B. Abramson, M.D., director of rheumatology and professor of medicine at New York University School of Medicine.
Now, the pendulum has swung the other direction, Abramson said. Prescribers are now more reluctant to prescribe NSAIDs because of the recent evidence of cardiovascular risks associated with the drugs, in addition to the well-documented gastrointestinal risks.
In 2006, the Osteoarthritis Research Society International (OARSI) formed an international committee to review all guidelines and evidence available on OA. The end result is a new set of 25, evidence-based recommendations for the treatment of hip and knee OA. Based on the evidence of potentially serious adverse reactions to NSAIDs, the committee has advised against the long-term use of NSAIDs to treat OA.
Long-term treatment options
Pharmacists might wonder what the long-term treatment options for OA are, if the NSAIDs are now out of favor. According to the new guidelines, no single drug or therapy is crowned as the ideal treatment for OA. Instead, a multi-modal approach chosen from a menu of options should be tailored for each individual patient. The OA menu is a list of treatments that the committee agreed are effective for use in the disease. The treatments are grouped in categories of pharmacologic, nonpharmacologic, and surgical therapies.
Included in the pharmacologic category of the guidelines are NSAIDs, acetaminophen, glucosamine, chondroitin, weak opioids, narcotic analgesics, topical capsaicin, and topical NSAIDs. Also included are intra-articular injections of corticosteroids and hyaluronate. They are recommended on a temporary basis according to severity of symptoms.
The guidelines have been well-received by arthritis specialists, according to Abramson. The challenge now is to disseminate the information. This is one area where pharmacists can play a huge role. Abramson said pharmacists need to counsel patients that multiple therapies may be needed to treat their OA. Pharmacists can advise patients on proper OTC use and help them select braces and orthotics. Abramson also said that although NSAID use is risky, patients should not be denied prescription NSAIDs if OTC remedies are ineffective. Pharmacists should also be on the alert for patients with OA who present prescriptions for opioids. Although these drugs can be of use in OA, Abramson said patients should be evaluated by a rheumatologist if they are to the point of needing opioids. A good specialist will use therapies in combination and in proper order.
Incorporating lifestyle changes
"One of the biggest challenges for pharmacists is to incorporate lifestyle modification into counseling points for patients with OA," said Kristen Binaso, R.Ph., a spokesperson for the American Pharmacists Association and a community pharmacist. Often, pharmacists focus on medication, but "we really need to stress these non-pharmacological changes," she said. Advising patients about proper footwear, for example, is an important, nonpharmacologic component in treating OA. It's also important to explain that acetaminophen and NSAIDs work differently, Binaso said.
Monitoring for adverse reactions and drug interactions is another invaluable pharmacy service, especially since OA patients are likely to take both prescription and OTC medications. Some patients may be reluctant to try non-drug methods or to pay for doctor visits and prescriptions when they can buy OTC remedies. Pharmacists can help guide them in the right direction. As Binaso put it, "I think it's a matter of helping patients set priorities."
The complete guidelines can be viewed on the OARSI Web site: http://www.oarsi.org/.
THE AUTHOR is a writer based in the Seattle area.