Topical NSAIDs
Place in Therapy
Diclofenac is the only NSAID approved for topical use in the United States (also the only OTC available topical NSAID in Canada). It has numerous trials supporting its efficacy in the treatment of hand and knee osteoarthritis in comparison to placebo. In general, application-site dermatitis was the most common adverse event, and gastrointestinal adverse events were rare. Unfortunately, direct head-to-head trials comparing topical NSAIDs to oral NSAIDs is lacking. There are some trials that show topical NSAIDs are at least equal in efficacy to oral NSAIDs in the treatment of osteoarthritis.
Therapeutic choices does not currently recommend topical analgesics in their treatment algorithm of osteoarthritis. However, they acknowledge topical diclofenac solution is as effective for pain relief of hand and knee osteoarthritis as oral NSAIDs. They also recognize that the incidence of GI bleeds is lower than in patients treated with oral NSAIDs and therefore they recommend topical NSAIDs over oral agents in persons ≥75 years old. This is in line with the 2012 American College of Rheumatology guidelines for the treatment of osteoarthritis.
All available North American guidelines (2008 AOOS and 2012 ACR) recommend non-pharmacological measures as first line treatment, however if adequate pain relief is not attained patients can use oral acetaminophen or oral NSAIDS. The guidelines also note that patients who are at increased risk (age 60 years or older, pre-existing comorbid medical conditions, history of peptic ulcer disease or gastrointestinal bleeding, and concomitant use of corticosteroids or anticoagulants) for gastrointestinal adverse events should avoid the use of oral NSAIDs. These patients should consider using acetaminophen, COX-2 selective NSAIDs, NSAIDs with a protective agent (i.e. Celebrex) or topical NSAIDs. The 2008 AOOS guidelines claim additional studies are needed for topical NSAIDs to verify clinical effectiveness, which was likely true in 2008. The most recent guidelines by the ACR in 2012 include topical NSAIDS as first-line pharmacological therapy in hand and knee osteoarthritis. The ACR guidelines also recommend topical NSAIDs over oral NSAIDs in patients ≥ 75 years of age, but do not comment specifically on therapy options for patients at high risk for oral NSAID-related gastrointestinal adverse events. Studies have shown elderly patients have been shown to prefer topical NSAIDs, based on the perception that a lower dose of the medication would be distributed throughout the body and therefore may result in less toxicity.
Clinical Bottom Line:
· Non-pharmacological interventions are first line in the treatment of osteoarthritis.
· Topical NSAIDs are at least equal in efficacy to oral NSAIDs in the treatment of osteoarthritis.
· Topical NSAIDs can be considered for first-line treatment of osteoarthritis, especially for patients at risk of gastrointestinal adverse events from oral NSAID use (age 60 years or older, pre-existing comorbid medical conditions, history of peptic ulcer disease or gastrointestinal bleeding, and concomitant use of corticosteroids or anticoagulants).
· Application-site dermatitis was the most common adverse event and gastrointestinal adverse events are rare with the use of topical NSAIDs.
Therapeutic choices does not currently recommend topical analgesics in their treatment algorithm of osteoarthritis. However, they acknowledge topical diclofenac solution is as effective for pain relief of hand and knee osteoarthritis as oral NSAIDs. They also recognize that the incidence of GI bleeds is lower than in patients treated with oral NSAIDs and therefore they recommend topical NSAIDs over oral agents in persons ≥75 years old. This is in line with the 2012 American College of Rheumatology guidelines for the treatment of osteoarthritis.
All available North American guidelines (2008 AOOS and 2012 ACR) recommend non-pharmacological measures as first line treatment, however if adequate pain relief is not attained patients can use oral acetaminophen or oral NSAIDS. The guidelines also note that patients who are at increased risk (age 60 years or older, pre-existing comorbid medical conditions, history of peptic ulcer disease or gastrointestinal bleeding, and concomitant use of corticosteroids or anticoagulants) for gastrointestinal adverse events should avoid the use of oral NSAIDs. These patients should consider using acetaminophen, COX-2 selective NSAIDs, NSAIDs with a protective agent (i.e. Celebrex) or topical NSAIDs. The 2008 AOOS guidelines claim additional studies are needed for topical NSAIDs to verify clinical effectiveness, which was likely true in 2008. The most recent guidelines by the ACR in 2012 include topical NSAIDS as first-line pharmacological therapy in hand and knee osteoarthritis. The ACR guidelines also recommend topical NSAIDs over oral NSAIDs in patients ≥ 75 years of age, but do not comment specifically on therapy options for patients at high risk for oral NSAID-related gastrointestinal adverse events. Studies have shown elderly patients have been shown to prefer topical NSAIDs, based on the perception that a lower dose of the medication would be distributed throughout the body and therefore may result in less toxicity.
Clinical Bottom Line:
· Non-pharmacological interventions are first line in the treatment of osteoarthritis.
· Topical NSAIDs are at least equal in efficacy to oral NSAIDs in the treatment of osteoarthritis.
· Topical NSAIDs can be considered for first-line treatment of osteoarthritis, especially for patients at risk of gastrointestinal adverse events from oral NSAID use (age 60 years or older, pre-existing comorbid medical conditions, history of peptic ulcer disease or gastrointestinal bleeding, and concomitant use of corticosteroids or anticoagulants).
· Application-site dermatitis was the most common adverse event and gastrointestinal adverse events are rare with the use of topical NSAIDs.