First line treatment
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| |
tablets 200mg, 400mg, 600mg
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syrup 100mg/5mL
|
GREEN Naproxen [Consider OTC/Self care]
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tablets 250mg, 500mg
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Gastrointestinal toxicity and cardiovascular toxicity are the two most important safety concerns for non-steroidal anti-
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inflammatory drugs (NSAIDs) and COX-2 inhibitors (coxibs). Clinical trial and epidemiological data have given important
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information on the level of risk with individual medicines. However, these data are complex and there are no robust
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comparisons for many NSAIDs. Most evidence relates to the coxibs, naproxen, ibuprofen, and diclofenac. The National
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Prescribing Centre (NPC) has summarised up-to-date prescribing advice and information in relation to NSAIDs, which is
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available through their website (www.npc.nhs.uk).
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Thrombotic risks
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In October 2006, the Commission on Human Medicines (CHM) gave advice on the latest evidence for cardiovascular thrombotic
|
risks:
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| > Diclofenac 150 mg daily has a thrombotic risk profile similar to that of at least one coxib (etoricoxib) and possibly others |
| > Naproxen 1000 mg daily has a lower thrombotic risk than coxibs and, overall, epidemiological data do not suggest an |
| increased risk of myocardial infarction |
| > For ibuprofen at high doses (eg, 2400 mg daily) there may be a small thrombotic risk, but at lower doses (eg, 1200 mg |
| daily |
| > For less) epidemiological data do not suggest an increased risk of myocardial infarction |
| |
Less evidence is available for other NSAIDs, but they may be associated with a small risk of thrombotic events, especially with long
|
duration of treatment and high doses.
|
| |
Cardiovascular risks
|
Results of two recently published epidemiological studies lend support to the view that some increase in thrombotic cardiovascular
|
risk may apply to all NSAID users, irrespective of their baseline risk, and not only to chronic users. The absolute increase in risk for
|
'healthy' users is very low. Current advice remains that patients should use the lowest effective dose and the shortest duration of
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treatment necessary to control symptoms. Overall evidence continues to indicate that naproxen is associated with a lower
|
thrombotic risk than coxibs. For ibuprofen, no significant increase in risk has been identified for doses of up to 1200mg daily.
|
Reference: Drug Safety Update, Volume 2 Issue 7, February 2009.
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Gastrointestinal risks
|
The Committee on Safety of Medicines (now the Commission on Human Medicines) has reviewed the relative gastrointestinal risks
|
of NSAIDs on several occasions. Recently, we have highlighted the high gastrointestinal risks with piroxicam, ketoprofen, and
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ketorolac. Of the traditional NSAIDs, low-dose ibuprofen offers the lowest risk. Coxibs are associated with reduced gastrointestinal
|
risk relative to most NSAIDs at equivalent doses. However, coxibs (like NSAIDs) may vary in their effects, and evidence for a
|
reduction in the most clinically important gastrointestinal risks for etoricoxib is weak. Proton pump inhibitors reduce the
|
gastrointestinal risks associated with NSAIDs, and may reduce the risks to a similar level as use of a coxib alone.
|
| |
Other NSAIDs
|
GREEN Diclofenac
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injection 25mg/mL
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| suppositories 12.5mg, 25mg, 50mg, 100mg |
GREEN Mefenamic acid
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capsules 250mg
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| tablets 500mg |
| |
Indometacin is usually recommended only for ankylosing spondylitis and gout.
|
GREEN Indometacin
|
| capsules 25mg, 50mg |
| suppositories 100mg |
| |
Patients over 65 years who are in high risk groups for developing ulcers (history of peptic ulcer or bleeding, cardiovascular
|
disease) should be given protection for the stomach when prescribed NSAIDs. NSAIDs and PPIs (Section 1.3.5) are often used
|
together for these at risk patients.
|
| |
Cox IIs (cyclo-oxygenase II selective inhibitors)
|
| |
The MHRA has issued the following general advice concerning all selective COX-2 inhibitors (Feb-05):
|
| > Patients with established ischaemic heart disease, cerebrovascular disease or peripheral arterial disease should be |
| switched to alternative treatment |
| > For all patients the balance of gastrointestinal and cardiovascular risk should be considered before prescribing a |
| COX-2 inhibitor, particularly for those with risk factors for heart disease and those taking low dose aspirin, for whom |
| gastrointestinal benefit has not been clearly demonstrated. |
| > The lowest effective dose of COX-2 inhibitor should be used for the shortest necessary period. Periodic re-evaluation |
| is recommended, especially for osteoarthritis patients who may only require intermittent treatment. |
| > Gastro-protective agents should be considered for patients switched to non-selective NSAIDs. |
| |
GREEN Celecoxib
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capsules 100mg, 200mg
|
GREEN Meloxicam
|
| tablets 7.5mg, 15mg |
AMBER Etoricoxib (Rheumatology initiation only)
|
| tablets 60mg, 90mg, 120mg |
| RED Parecoxib 40mg powder and solvent for solution for injection - for use in prevention of post-operative pain |
| (administration in theatres) and pain management for patients with poor absorption or nil by mouth as an alternative |
| to IV diclofenac. |
| RED Parecoxib 40mg powder and solvent for solution for injection - Adjunct therapy for the treatment of refractory non- |
| surgical cancer pain - see syringe pump policy |
| |
Osteoarthritis - NICE Clinical Guideline 177 February 2014
|
Treatment and management
|
| |
Core treatment:
|
There are three core interventions which should be considered for every person with osteoarthritis:
|
| > access to appropriate patient information sources, |
| > activity and exercise, |
| > interventions to achieve weight loss if person is overweight or obese. |
| |
If further treatment is required then adjunctive treatments should be considered;
|
| |
| > Paracetamol (regular dosing may be required). AND/OR |
| > topical non steroidal anti-inflammatory drugs (NSAIDs) or topical capsaicin for knee or hand osteoarthritis |
| |
If above agent/s are ineffective or insufficient then consider;
|
| > Substitution or addition of an oral NSAID or COX-2 inhibitor (but NOT eterocoxib) OR |
| > Opioid analgesics |
| |
Consider intra-articular corticosteroid injections if pain is moderate to severe.
|
| |
Treatment with oral NSAIDs/COX-2 inhibitors:
|
All oral NSAIDs/COX-2 inhibitors have similar analgesic effects but vary in their gastrointestinal, liver and cardio-renal toxicity. This
|
should be taken into account when choosing the drug and dose for an individual patient.
|
| |
Treatment with oral NSAIDs/COX-2 inhibitors:
|
| > Prescribe the lowest effective dose for the shortest possible period of time, |
| > ALWAYS co-prescribe a proton pump inhibitor (PPI) - choose one with the lowest cost. |
| > Assess patient risk factors for gastrointestinal, liver and cardio-renal toxicity, |
| > Consider ongoing monitoring of patient risk factors, |
| > Use an alternative analgesic if patient is taking low-dose aspirin. |
| |
Treatment with opioids:
|
| > Consider the risks and benefits particularly in elderly people. |
| > Adverse effects: constipation, nausea, itchiness, drowsiness and confusion |
| |
Non-pharmacological:
|
| > Application of heat or cold to the site of pain. |
| > Transcutaneous electrical nerve stimulation (TENS). |
| > Manipulation and stretching, particularly for hip osteoarthritis. |
| > Assessment for bracing/joint supports/insoles for people with biomechanical joint pain or instability. |
| > Assistive devices (for example, walking sticks and tap turners) for people with specific problems with daily activities. |
| Expert advice may be required. |
| |
Treatments not recommended
|
| > Rubefacients |
| > intra-articular hyaluronan injections | | > electro-acupuncture | | > chondroitin or glucosamine products | |
| |
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