1. Weigh available therapy options and guidelines. It goes without saying that every patient is different, and so, too, is their pain. An effective medical approach to pain management can help patients stave off the need for surgery. The American Academy of Orthopaedic Surgeons (AAOS) recommends either acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) to help control pain from OA of the knee.[3] It is noted that NSAIDs appear to reduce pain significantly more than acetaminophen; however, NSAIDs may have serious gastrointestinal side effects.[4]
NSAID side effects may be reduced by using topical, rather than oral, formulations. For patients with increased GI risk — those aged 60 or older, with comorbid medical conditions or with a history of GI problems — topical NSAIDs are recommended by AAOS.[5] Studies show that topical NSAIDs are as effective as, and possibly safer than, oral formulations.[6],[7] A recent analysis of two pooled studies showed patients receiving topical NSAIDs — such as those in liquid, gel or patch form — had significantly fewer GI-related adverse events than with oral NSAIDs.[8]
2. Optimize treatment with complementary, non-medical activities. Increasingly, evidence points to lifestyle changes, alongside pharmacological treatment, as critical to relieving knee OA pain. Particularly for patients who present with moderate or severe pain, and who have already tried over-the-counter pain medicines without success, non-medical interventions such as physical therapy, exercise and water therapy can bolster pain control in order to improve function.
Not surprisingly, weight loss also plays a key role. Studies have shown consistently that weight loss can lessen pain and improve physical function.[9] Excessive loading on joints may lead to greater pain, and, in a vicious cycle, faster progression of the disease and the joint cannot be strengthened when inactive. For this reason, improving physical function has become a key goal in knee OA pain management.
3. Bridge the gap between research and clinical practice. Recent clinical breakthroughs, and clinical trials in progress, point to continued sector growth and new OA pain management options for patients and physicians. Clinical practice must keep up with these trends, but should also consider carefully the practical applications for each patient.
The American College of Rheumatology is rewriting its guidelines for OA management and the new guidelines will likely include topical NSAIDs. Some of the latest advances in topical pain drugs include new diclofenac applications. Beginning in 2007, a doctor-prescribed diclofenac patch, gel and topical solution were approved separately for use in the United States.
The goal of pain management — whatever form it may take — is to help patients achieve and maintain an active life. These simple best practices show that nonsurgical options, both pharmacological and lifestyle, can help patients manage and improve symptoms, preserve their mobility and the health of their knees, and avoid surgery.
Learn more about Dr. Charles Argoff.
Editor’s note: The author acknowledges receiving honoraria from Covidien, the supplier of PENNSAID®, as a consultant and speaker.
[1] Osteoarthritis costs U.S. $185B a year http://www.usatoday.com/news/health/2009-12-04-osteoarthritis_N.htm [Last accessed August 16, 2010]
[2] Zhang W, et al. OARSI recommendations for the management of hip and knee osteoarthritis Part III: changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis and Cartilage 18 (2010) 476–499.
[3] American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Treatment of Osteoarthritis of the Knee (Non-Arthroplasty). Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2008.
[4] Herrero BG, Ivorra JA, Del Carmen TM, Blanco FJ, Benito P, Martin ME, et al. “Glucosamine sulfate in the treatment of knee osteoarthritis symptoms: a randomized double-blind, placebo-controlled study using acetaminophen as a side comparator.” Arthritis Rheum 2007;56:555-67.
[5] American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Treatment of Osteoarthritis of the Knee (Non-Arthroplasty). Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2008.
[6] Evans JM, MacDonald TM. “Tolerability of topical NSAIDs in the elderly: do they really convey a safety advantage?” Drugs Aging 1996;9:101-8.
[7] Evans JMM, McMahon AD, McGilchrist MM, White G, Murray FE, McDevitt DG, et al “Topical non-steroidal anti-inflammatory drugs and admission to hospital for upper gastrointestinal bleeding and perforation: a record linkage case-control study.” BMJ 1995;311:22-6.
[8] Roth S. “Topical diclofenac solution (PENNSAID®) compared with oral diclofenac in osteoarthritis of the knee: pooled analysis from 2 controlled clinical trials>”topical NSAIDs had significantly fewer GI-related adverse events than oral.
[9] Christensen R, Bartels EM, Astrup A, Bliddal H. “Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review.” Ann Rheum Dis 2005;64:544-8.
