Osteoarthritis treatment
https://www.nice.org.uk/guidance/cg177/resources/guidance-osteoarthritis-pdf
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
Original post by asaaal
https://www.nice.org.uk/guidance/cg177/resources/guidance-osteoarthritis-pdf
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
Look in the BNF.
Although I would assume it just means your routine painkillers 1st line e.g. paracetamol and ibuprofen.
Original post by Dexa
Look in the BNF.
Although I would assume it just means your routine painkillers 1st line e.g. paracetamol and ibuprofen.
Although I would assume it just means your routine painkillers 1st line e.g. paracetamol and ibuprofen.
The BNF just tells you as part of the indications but not what to give first line etc
Original post by asaaal
https://www.nice.org.uk/guidance/cg177/resources/guidance-osteoarthritis-pdf
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
I've seen diclofenac, naproxen and ibuprofen in use. Diclofenac is more potent than ibuprofen.
Nefopam (different class) can be used for pain management arthritis, I can't remember exactly but I think it is more specifially used in knee arthritis when NSAIDs and paracetamol have failed.
Original post by asaaal
The BNF just tells you as part of the indications but not what to give first line etc
You're looking at it too literally. If it says prescribe a topical NSAID first line, then you base the choice on the patient's preferences, tolerability, previous success with the drug, possible interactions with current medications etc. You could just start them on topical ibuprofen and review them at a later date to see how they get on with it. If they don't tolerate it, try something else or move onto the second line i.e. paracetamol or oral NSAID.
That's the whole purpose of a guideline, it's not literally meant to tell you what to do, it's just their to guide your management.
Original post by TheRabbit
I've seen diclofenac, naproxen and ibuprofen in use. Diclofenac is more potent than ibuprofen.
Nefopam (different class) can be used for pain management arthritis, I can't remember exactly but I think it is more specifially used in knee arthritis when NSAIDs and paracetamol have failed.
Nefopam (different class) can be used for pain management arthritis, I can't remember exactly but I think it is more specifially used in knee arthritis when NSAIDs and paracetamol have failed.
Original post by Dexa
You're looking at it too literally. If it says prescribe a topical NSAID first line, then you base the choice on the patient's preferences, tolerability, previous success with the drug, possible interactions with current medications etc. You could just start them on topical ibuprofen and review them at a later date to see how they get on with it. If they don't tolerate it, try something else or move onto the second line i.e. paracetamol or oral NSAID.
That's the whole purpose of a guideline, it's not literally meant to tell you what to do, it's just their to guide your management.
That's the whole purpose of a guideline, it's not literally meant to tell you what to do, it's just their to guide your management.
Very kind of you both to reply.
Thank you for your help, very much appreciated
Original post by asaaal
https://www.nice.org.uk/guidance/cg177/resources/guidance-osteoarthritis-pdf
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
I would probably start them off on a weak-ish topical NSAID, e.g. ibuprofen 5% gel, then go onto a stronger topical NSAID, e.g. diclofenac 1% emulgel, then increase the strength to diclofenac 2.32% emulgel, then consider oral NSAIDs, e.g. diclofenac 50 mg tabs, and then move onto coxibs (much more selective for COX-2 than diclofenac), e.g. celecoxib 200 mg tabs.
Original post by asaaal
https://www.nice.org.uk/guidance/cg177/resources/guidance-osteoarthritis-pdf
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
The NICE guideline doesn't say which topical NSAID, oral NSAID or COX-2 inhibitor to give.
Can anyone help?
BNF guidelines: http://www.evidence.nhs.uk/formulary/bnf/current/10-musculoskeletal-and-joint-diseases/101-drugs-used-in-rheumatic-diseases-and-gout/osteoarthritis-and-soft-tissue-disorders.
As I mentioned in my previous post, I would start off with less potent NSAIDs like ibuprofen and then work my way up to more potents ones like diclofenac. As Helenia mentioned above, remember to co-prescribe a PPI for peptic ulcer prophylaxis in long term NSAID use.
Original post by Etomidate
I would keep my ear to the ground regarding diclofenac and the selective COXs RE:?cardiovascular risk. Naproxen hasn't yet been caught in the crossfire, as far as I'm aware.
(Also remember that topical NSAIDs can be enough to push a little old lady into AKI).
(Also remember that topical NSAIDs can be enough to push a little old lady into AKI).
Yeah, that's the issue with the coxibs - they're relatively new on the market and so don't really have any long term studies showing morbidity/mortality risks. Rofecoxib has already been taken off the market due to very serious cardiovascular side effects, but celecoxib is still on (as well as others - not sure?). The pharmacy I worked at last summer only stocked it for one regular patient - not too sure what indication it was for though.
Hmm, I think someone would have to take topical NSAIDs for a very long time and at a high dose to cause an AKI. Oral NSAIDs on the other hand...
(edited 9 years ago)
Original post by thegodofgod
Hmm, I think someone would have to take topical NSAIDs for a very long time and at a high dose to cause an AKI. Oral NSAIDs on the other hand...
Well, little old ladies either don't understand fingertip units or have very large fingertips!
Original post by Etomidate
Well, little old ladies either don't understand fingertip units or have very large fingertips!
To be honest, I have a feeling that some don't think that topical medicines can be as potent as oral medicines - I think they would probably be more likely to apply a gel more times a day than prescribed, as opposed to tablets.
Original post by thegodofgod
To be honest, I have a feeling that some don't think that topical medicines can be as potent as oral medicines - I think they would probably be more likely to apply a gel more times a day than prescribed, as opposed to tablets.
I think you're probably right!
Original post by Etomidate
I think you're probably right!
Original post by thegodofgod
To be honest, I have a feeling that some don't think that topical medicines can be as potent as oral medicines - I think they would probably be more likely to apply a gel more times a day than prescribed, as opposed to tablets.
so bottom line is to use less potent NSAIDs like ibuprofen then a more potent one like diclofenac or naproxen? They are both available in oral and topical form aren't they.
What cox-2 inhibitor would you give first and what next?
Original post by asaaal
so bottom line is to use less potent NSAIDs like ibuprofen then a more potent one like diclofenac or naproxen? They are both available in oral and topical form aren't they.
What cox-2 inhibitor would you give first and what next?
What cox-2 inhibitor would you give first and what next?
I would probably stick to oral paracetamol first line, with topical ibuprofen sparingly for hand OA (alternatively, can use topical capsaicin 0.025%) or short courses of oral ibuprofen/naproxen if necessary (+/- PPI). Failing that you could consider opioids or corticosteroid/LA injections.
The most common cox inhibitor could probably be celecoxib. But I would probably seek advice before I prescribed it myself.
(edited 9 years ago)
Original post by asaaal
so bottom line is to use less potent NSAIDs like ibuprofen then a more potent one like diclofenac or naproxen? They are both available in oral and topical form aren't they.
What cox-2 inhibitor would you give first and what next?
What cox-2 inhibitor would you give first and what next?
As Etomidate said above. Yeah, ibuprofen and diclofenac are available as tablets and as gels. I know naproxen is available as normal and enteric-coated tablets, but I'm not sure if it comes in a topical formulation - I've never seen it being prescribed or dispensed in such a form.
Celecoxib and etoricoxib are both licensed for pain relief in osteoarthritis, but I'd probably go for celecoxib first because I've seen it being used before, whereas I haven't seen etoricoxib used. Parecoxib is another selective COX-2 inhibitor, but it is not licensed for use in osteoarthritis - it is licensed for short-term post-operative pain relief.
EDIT: Also, celecoxib (Celebrex) is cheaper than etoricoxib (Arcoxia).
(edited 9 years ago)
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