Choice of drug

These drugs are not curative but they do control pain and stiffness. The usual initial therapy is to start with an arylalkanoic acid derivative, e.g. ibuprofen or naproxen. Alternative first choice treatments include diclofenac, flurbiprofen or sulindac.

• if a particular drug does not appear effective after 2-3 weeks then switch to another non-steroidal. Switches of drug may be within particular subclasses of arylalkanoic acid, e.g. ibuprofen to naproxen - both propionic acid derivatives; or between subclasses, e.g. ibuprofen to sulindac - acaetic acid derivative

NICE suggest that paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclo-oxygenase 2 (COX-2) inhibitors or opioids in the management of osteoarthritis (OA):

• if paracetamol or topical NSAIDs are insufficient for pain relief for people with osteoarthritis, then the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in elderly people
• topical NSAIDs and/or paracetamol should be considered ahead of oral NSAIDs, COX-2 inhibitors or opioids
• topical capsaicin should be considered as an adjunct to core treatment for knee or hand osteoarthritis
• rubefacients are not recommended for the treatment of osteoarthritis
  
  
• use of oral NSAIDs/COX-2 inhibitors
  • where paracetamol or topical NSAIDs are ineffective for pain relief for people with osteoarthritis, then substitution with an oral NSAID/COX-2 inhibitor should be considered
  • where paracetamol or topical NSAIDs provide insufficient pain relief for people with osteoarthritis, then the addition of an oral NSAID/COX-2 inhibitor to paracetamol should be considered
  • oral NSAIDs/COX-2 inhibitors should be used at the lowest effective dose for the shortest possible period of time
  • when offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg). In either case, these should be co-prescribed with a PPI, choosing the one with the lowest acquisition cost
  • if a person with osteoarthritis needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2 inhibitor (with a PPI) if pain relief is ineffective or insufficient

Reference:

• (1) NICE (February 2014).Osteoarthritis The care and management of osteoarthritis in adults