NSAIDs
Place in Therapy
Ibuprofen (Advil) and naproxen sodium (Alleve) are available in Canada without a prescription. OTC doses of naproxen sodium (220mg) and ibuprofen (200-400mg) effectively relieve pain in patients with mild to moderate osteoarthritis.1-5 Nonsteroidal anti-inflammatories (NSAIDS) are typically considered second-line therapy after failure of acetaminophen therapy in the management of osteoarthritis pain.2-5 This designation is generally due to their increased risk of serious adverse effects.2-5 Osteoarthritis patients often prefer NSAIDS over the safer option acetaminophen due to their superior pain relief. 6-8 Patients should be assessed for any medical conditions of concern including cardiovascular conditions, gastrointestinal bleeds and renal complications. If a patient has no risk factors, a low-dose of NSAID can be initiated. Typical starting doses are: ibuprofen 200-400mg Q8H and naproxen sodium 220mg Q12H. The maximum daily dose for non-prescription ibuprofen is 1200mg and 440mg for naproxen. 2-5, 9-10
Long-term therapy of naproxen and ibuprofen should be avoided if possible. If continued therapy is needed, it is advised to use the lowest effective dose.10-11 Patients requiring chronic use of NSAID therapy for osteoarthritis should visit their family physician to discuss the risks and benefits of long-term use. The most common adverse drug reaction with NSAID use is dyspepsia, with prevalence reports of up to 60% in patients. Serious GI complications such as ulcers, hemorrhage and internal bleeding should be monitored closely upon immediate discontinuation of NSAID therapy. H2-antagonists and antacids provide relief from dyspepsia but do not prevent GI complications. Proton pump inhibitors are appropriate options for GI complications and ulcer prevention, but require prescription therapy.10-11
References:
1. Schiff M, Minic M. Comparison of the Analgesic Efficacy and Safety of Nonprescription Doses of Naproxen Sodium and Ibuprofen in the Treatment of Osteroarthristis. J Rheumatol.2004; 31:1373-83
2. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000; 43:1905-15.
3. Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. American College of Rheumatology. Arthritis Rheum 1995; 38:1541.
4. Zhang W, Moskowitz RW, Nuki G et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-62.
5. Jordan KM, Arden NK, Doherty M et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISTI), Ann Rhem Dis. 2003;62:1145-55.
6. Pincus T, Swearingen C, Cummins P et al. Preference for nonsteroidal anti-inflammatory drugs versus acetaminophen and concomitant use of both types of drugs in patients with osteoarthritis. J Rheumatol. 2000; 27:1020-7
7. Wolfe F, Zhao S, Lane N. Preference of nonsteroidal anti-inflammatory drugs over acetaminophen by rheumatic disease patients: a survey of 1,799 patients with osteoarthritis, rheumatoid arthritis, and fibromyalgia. Arthritis Rheum. 2000; 43:378-85.
8. Boureau F, Schneid H, Zeghari N, Wall R, Bourgeois P. The IPSO study: ibuprofen, paracetamol study in osteoarthritis. A randomized comparative clinical study comparing the efficacy and safety of ibuprofen and paracentamol analgesic treatment of osteoarthritis of the knee or hip. Ann Rheum Dis. 2004; 63:1028-1034.
9. Lexicomp Online, Naproxen/Ibuprofen, Hudson, Ohio: Lexi-Comp, Inc.; 2013. Accessed March 7, 2014.
10. Kalunian KC, MD. Pharmacologic therapy of osteoarthritis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.
11. Grindrod K, Marra Carlo. Patient Self-Care: Osteoarthritis. Canadian Pharmacists Association. 2010;48:456-469.
Long-term therapy of naproxen and ibuprofen should be avoided if possible. If continued therapy is needed, it is advised to use the lowest effective dose.10-11 Patients requiring chronic use of NSAID therapy for osteoarthritis should visit their family physician to discuss the risks and benefits of long-term use. The most common adverse drug reaction with NSAID use is dyspepsia, with prevalence reports of up to 60% in patients. Serious GI complications such as ulcers, hemorrhage and internal bleeding should be monitored closely upon immediate discontinuation of NSAID therapy. H2-antagonists and antacids provide relief from dyspepsia but do not prevent GI complications. Proton pump inhibitors are appropriate options for GI complications and ulcer prevention, but require prescription therapy.10-11
References:
1. Schiff M, Minic M. Comparison of the Analgesic Efficacy and Safety of Nonprescription Doses of Naproxen Sodium and Ibuprofen in the Treatment of Osteroarthristis. J Rheumatol.2004; 31:1373-83
2. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000; 43:1905-15.
3. Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. American College of Rheumatology. Arthritis Rheum 1995; 38:1541.
4. Zhang W, Moskowitz RW, Nuki G et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-62.
5. Jordan KM, Arden NK, Doherty M et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISTI), Ann Rhem Dis. 2003;62:1145-55.
6. Pincus T, Swearingen C, Cummins P et al. Preference for nonsteroidal anti-inflammatory drugs versus acetaminophen and concomitant use of both types of drugs in patients with osteoarthritis. J Rheumatol. 2000; 27:1020-7
7. Wolfe F, Zhao S, Lane N. Preference of nonsteroidal anti-inflammatory drugs over acetaminophen by rheumatic disease patients: a survey of 1,799 patients with osteoarthritis, rheumatoid arthritis, and fibromyalgia. Arthritis Rheum. 2000; 43:378-85.
8. Boureau F, Schneid H, Zeghari N, Wall R, Bourgeois P. The IPSO study: ibuprofen, paracetamol study in osteoarthritis. A randomized comparative clinical study comparing the efficacy and safety of ibuprofen and paracentamol analgesic treatment of osteoarthritis of the knee or hip. Ann Rheum Dis. 2004; 63:1028-1034.
9. Lexicomp Online, Naproxen/Ibuprofen, Hudson, Ohio: Lexi-Comp, Inc.; 2013. Accessed March 7, 2014.
10. Kalunian KC, MD. Pharmacologic therapy of osteoarthritis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.
11. Grindrod K, Marra Carlo. Patient Self-Care: Osteoarthritis. Canadian Pharmacists Association. 2010;48:456-469.