First line treatment |
|
tablets 200mg, 400mg, 600mg |
syrup 100mg/5mL |
GREEN Naproxen [Consider OTC/Self care] |
tablets 250mg, 500mg |
|
Gastrointestinal toxicity and cardiovascular toxicity are the two most important safety concerns for non-steroidal anti- |
inflammatory drugs (NSAIDs) and COX-2 inhibitors (coxibs). Clinical trial and epidemiological data have given important |
information on the level of risk with individual medicines. However, these data are complex and there are no robust |
comparisons for many NSAIDs. Most evidence relates to the coxibs, naproxen, ibuprofen, and diclofenac. The National |
Prescribing Centre (NPC) has summarised up-to-date prescribing advice and information in relation to NSAIDs, which is |
available through their website (www.npc.nhs.uk). |
|
Thrombotic risks |
In October 2006, the Commission on Human Medicines (CHM) gave advice on the latest evidence for cardiovascular thrombotic |
risks: |
> 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 |
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. |
|
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 |
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 |
injection 25mg/mL |
suppositories 12.5mg, 25mg, 50mg, 100mg |
GREEN Mefenamic acid |
capsules 250mg |
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 |
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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