Osteoarthritis

Prescribing Notes:

• Topical NSAIDs in the treatment of osteoarthritis should only be considered for treatment of the hands and knees. If treatment has been ineffective after 4 weeks, then it should be discontinued.
• Topical NSAIDs may be used for short term acute treatment of sprains and strains (up to 7 days).
• Patients should be advised against excessive exposure to sunlight of areas treated with topical NSAIDs in order to avoid the possibility of photosensitivity.

Prescribing Notes:

For older patients and other patients at high risk of gastro-intestinal adverse events:

• Prescribe a NSAID (as shown in this pathway) + omeprazole or lansoprazole (see the ‘NSAID-associated ulcers and dyspepsia’ pathway in the Gastro-intestinal chapter of the formulary.

Additional prescribing notes:

• Rubefacients are not recommended for the treatment of osteoarthritis.
• NICE guidance for osteoarthritis recommends paracetamol and/or topical NSAIDs may be considered before oral NSAIDs.
• Patients that require NSAIDs should be prescribed them at the lowest effective dose and long term use should be avoided if possible.
• Diclofenac is contraindicated in those with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease or established heart failure. The arterial thrombosis risk with diclofenac is similar to that of the COX-2 inhibitors.
• Low dose ibuprofen is considered to have the most favourable thrombotic cardiovascular safety profile.
• For patients with cardiovascular and cerebrovascular disease, current evidence suggests that the risk of heart failure is increased with all NSAIDs. The risk of myocardial infarction is also increased with most NSAIDs, with the possible exception of naproxen. The risk of stroke is increased with most NSAIDs with the possible exception of low dose (<200mg daily) celecoxib.
• Contra-indications to NSAIDs include proven hypersensitivity to aspirin or any NSAID, severe heart failure and active gastrointestinal bleeding. They should be used with caution in patients with mild-moderate heart failure, renal impairment and history of peptic ulceration.
• NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma.
• Long-term use of high dose ibuprofen may interfere with the cardioprotective effects of low dose aspirin. Naproxen may be a suitable alternative.
• Patients at high risk of gastrointestinal (GI) adverse effects should be prescribed NSAID + PPI, see the ‘NSAID-associated ulcers and dyspepsia’ pathway in the Gastro-intestinal chapter of the formulary. Risk factors for GI adverse effects include previous peptic ulcer, previous GI bleed, alcohol excess, systemic corticosteroids, anticoagulants, SSRIs, age>65 years, high dose NSAIDs.
• Oral NSAIDs are excluded from the inpatient analgesic strategy for severe or distressing acute musculoskeletal pain in patients aged >65years. This is due to increased risk of serious GI toxicity and perforation, increased risks of renal impairment and increased cardiovascular risks. Topical NSAIDs may be appropriate, see below.
• During long term use of NSAIDs ensure appropriate monitoring and regular re-evaluation of clinical need.
• Modified release preparations should not be prescribed as initial treatment but may be of benefit in patients with inflammatory arthritis who remain symptomatic on standard preparations e.g. the treatment of night-time pain or early morning stiffness.
• Patients should be advised against excessive exposure to sunlight of areas treated with topical NSAIDs in order to avoid the possibility of photosensitivity.