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Musculoskeletal pain. NSAIDs, analgesics and non-drug approaches. Targeting treatment in OA. Other pharmaceutical options. Core Treatments. Other non-drug treatments. Self-management techniques. Relatively safe pharmaceutical options. Surgery.

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musculoskeletal pain

Musculoskeletal pain

NSAIDs, analgesics and non-drug approaches

targeting treatment in oa
Targeting treatment in OA

Other pharmaceutical options

Core Treatments

Other non-drug treatments

Self-management techniques

Relatively safe pharmaceutical options


NICE Clinical Guideline 59:Osteoarthritis, Feb 2008

houston we have a problem 1 merec extra issue 30 november 2007
Houston, we have a problem…(1)MeReC Extra Issue 30. November 2007
  • All NSAIDscarry a risk of GI side effects
    • Risk increases with age, presence of comorbidities and dose of NSAID
  • Coxibshave a lower GI risk than traditional NSAIDs
    • Dyspepsia can still occur and may be as common as with traditional NSAIDs
    • Severe and sometimes fatal GI reactions can occur
    • Benefits diminished when co-administered with aspirin
  • Low-dose ibuprofen has a lower GI risk than diclofenac and naproxen
  • Using a PPI significantly reduces the risk of serious GI adverse effects and dyspepsia with any NSAID
    • No good evidence that adding a PPI to a coxib is more beneficial than adding a PPI to a traditional NSAID
houston we have a problem 2 merec extra issue 30 november 2007
Houston, we have a problem…(2)MeReC Extra Issue 30. November 2007
  • Coxibs cause a small increased absolute risk of thrombotic events compared with placebo
    • The excess risk is estimated to be about 3 cases per 1000 users treated for 1 year on average
    • This risk increases with dose and persists throughout treatment
    • All coxibs are contraindicated for patients with established ischaemic heart disease, peripheral arterial disease and/or cerebrovascular disease
  • Diclofenac150mg/d has a thrombotic risk profile similar to that of the coxibs
  • Ibuprofen 1200mg/d and naproxen1000mg/d have a lower thrombotic risk
  • Cardio-renal effects seem to apply to all NSAIDs and selective COX-2 inhibitors, and contribute to CV risk
cv risks it s a volume thing merec extra issue 30 november 2007
CV risks? It’s a volume thing…MeReC Extra Issue 30. November 2007
  • Prescribing of coxibsmay be responsible for approximately 240additional or premature CV events per year in England alone
  • Approximately 2000additional or premature CV events per year could be caused by diclofenac prescribing

NSAID prescribing in England April to June 2007: % total items (4.3 million)

what do we need to consider
What do we need to consider?

For the individual patient there will be a trade-off along each of these dimensions

Cardiovascular risks

Symptoms and response to treatment

Gastrointestinal risks

so what s the deal
So, what’s the deal?

For patients taking NSAIDs which carry a higher CV risk:

  • Switching to paracetamol 4g/day
    • Will reduce cardiovascular risk
    • Will reduce gastrointestinal risk
    • Efficacy?
  • Switching to ibuprofen 1200mg/day
    • Will reduce cardiovascular risk
    • Will reduce gastrointestinal risk (especially if use a PPI as well)
    • Efficacy?
  • Switching to naproxen 1g/day
    • Will reduce cardiovascular risk
    • May increase gastrointestinal risk (but what about using a PPI?)
    • Efficacy?
who should we prioritise for review
Who should we prioritise for review?
  • People at high GI risk
    • Age >65 years
    • History of GI bleeding, ulcer or perforation
    • Those taking medicines that increase risk of upper-GI AEs (eg warfarin, aspirinand corticosteroids)
    • Serious comorbidity, eg CV disease, renal or hepatic impairment, diabetes or hypertension
    • Prolonged duration or maximum doses of NSAID
    • Excessive alcohol use
    • Heavy smoking
  • People at high CV risk
    • Those with established CVD
    • Those taking CV medication, especially aspirin and clopidogrel
    • Older men
    • Smokers
    • People with diabetes
  • Some risk factors increase both CV and GI risk — people with these need particular attention
three steps to nsaid heaven tm
Three steps to NSAID heavenTM
  • Don’t use them unless you have to
    • The only way to avoid NSAID side effects is not to use them
    • Paracetamol works for many
    • Employ non-drug interventions routinely
    • Consider topical NSAIDs ahead of oral NSAIDs for OA
  • If you have to use them, use them wisely
    • The balance of benefits and risks needs to be carefully assessed; think about CV, GI and renal issues routinely
    • Use a safer drug (ibuprofen, then naproxen) in the lowest effective dose for the shortest period
    • NSAID users should be a high priority for medication review: are NSAIDs effective/needed? Drug holidays? Don’t issue repeat prescriptions without review
  • Consider gastroprotection in those at high risk
    • Options are PPIs, double-dose H2RAs, misoprostol
    • Co-prescribe PPI with NSAID for OA

All of this particularly applies to those aged over 65 years