Download Osteoarthritis (Degenerative Joint Disease)

Scientific Reference Guide Osteoarthritis
(Degenerative Joint Disease)
Updated February 2005
What are the best treatments?
Description of Condition
Osteoarthritis is the most common cause of chronic joint pain, stiffness, and immobility among persons in
the United States. The areas that are most often affected are the fingers, knees, and hips. Also known as
degenerative joint disease, osteoarthritis is thought to result from a wear and tear process in which the cartilage that normally cushions the space between the joints becomes thin and less elastic. In contrast to
rheumatoid arthritis, the second most common form of chronic arthritis in the United States, inflammation plays a relatively small role in osteoarthritis. In its mild form, osteoarthritis causes joint pain that is frequently worsened by strenuous activity. In its more severe form, osteoarthritis can substantially impair
mobility and functioning.
Nonprescription Interventions and When to Seek Help
The major treatment options for osteoarthritis are a combination of rest and exercise; use of a variety of topical, oral, and injectable medications; and surgery. By resting sore joints, activities that routinely worsen
symptoms are avoided. Certain isometric and strengthening regimens have been shown to reduce pain and
improve function in osteoarthritis of the knee and, possibly, the hip. It is often helpful to consult with a physical therapist. A variety of over-the-counter medicines are effective for reducing pain. These include acetaminophen (Tylenol®), aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (e.g.,
Advil®, Nuprin®, Motrin®) and naproxen (Aleve®).
Most patients with osteoarthritis can manage their own disease through a combination of adequate rest,
strength training, and over-the-counter medication. Patients should seek prompt medical attention if they
develop redness and swelling in one or more joints, as this could indicate an infection or another form of
arthritis such as gout. Other indications for medical consultation include unrelenting pain and impaired
functioning (such as the inability to perform activities at home, work, or school).
Categories of Prescription Pharmaceutical Treatments (i.e., Drug Classes)
Prescription medications that are available for the treatment of osteoarthritis include NSAIDs, cyclooxygenase-2 inhibitors (COX-2 inhibitors), and opiates (usually prescribed in combination with acetaminophen).
Both NSAIDs and COX-2 inhibitors reduce pain and inflammation by inhibiting the formation of chemicals called prostaglandins. In contrast, opiates act in the brain and spinal cord to reduce pain. Opiates are
effective painkillers; however, they can result in constipation and drowsiness and are also potentially habit
forming. Consequently, they are not recommended as first-line therapy. Acetaminophen (e.g., Tylenol) and
many NSAIDs are available over the counter. The Table shows the costs of commonly available NSAIDs and
COX-2 inhibitors.
Intraclass Comparisons
■ Acetaminophen is safe and effectively reduces the pain associated with mild osteoarthritis.
■ In clinical studies, there have been no reports of differences in average efficacy among commonly
prescribed NSAIDS. However, some patients may respond better to one preparation than another.
■ The manufacturer of VIoxx (rofecoxib) recently withdrew this medication from the market because
of concerns over an increased risk of heart attacks and strokes. More recent developments have led
many experts to conclude that currently available COX-2 inhibitors (celecoxib and valdecoxib)
should not be used as first line agents for treatment of degenerative joint disease (osteoarthritis).
In addition, they should be avoided in patients at high risk for cardiovascular disease.
Page 1
Scientific Reference Guide Osteoarthritis
■
(Degenerative Joint Disease)
Topical capsaicin (available by prescription) and oral glucosamine with or without chondroitin sulfate (available as a dietary supplement) both reduce symptoms more than placebo and may be reasonable options in
patients with mild to moderate pain. Intraarticular hyaluronan injections reduce pain for osteoarthritis of the
knee for 1 to 6 months but may require multiple office visits.
Interclass Comparisons
■ When used in appropriate doses, there are no differences in efficacy between COX-2 inhibitors and other
NSAIDS for the relief of osteoarthritic pain.
■ Like other NSAIDs, COX-2 inhibitors can impair renal function and increase blood pressure. Recent data
on rofecoxib have raised concerns about the possible adverse cardiovascular effects of COX-2 inhibitors as a
class, but more research is needed.
■ COX-2 inhibitors probably cause less gastrointestinal (GI) bleeding than other NSAIDs, but the absolute
differences are small (about 1%). Differences in study populations and dosing complicate assessment of this
adverse effect.
■ Adding aspirin to COX-2 inhibitors (e.g., to prevent heart attacks) may negate their advantage in terms of
GI bleeding.
■ All NSAIDS, including COX-2 inhibitors, are associated with increased risk of upper GI bleeding in patients
with a history of upper GI bleeding.
■ Despite a recent clinical study suggesting that Aleve (naproxen sodium) was associated with a small increased
risk of cardiac events, it is premature to draw any new conclusions about the cardiovascular safety of
naproxen. However, like all medications, naproxen and other NSAIDS should be used at the lowest effective dose for the shortest possible period of time.
Conclusions
■ Persons with chronic, symmetric joint discomfort and no signs of inflammation or systemic disease can
safely try to manage symptoms of osteoarthritis with nonpharmacological measures (e.g., rest and exercise),
acetaminophen, and standard NSAIDs in low doses taken for up to 2 weeks at a time. Patients with liver
or kidney disease or a history of GI bleeding should always discuss the use of acetaminophen or NSAIDs
with their physicians.
■ In general, NSAIDs and COX-2 inhibitors are equally effective in relieving pain associated with osteoarthritis.
■ New safety concerns about COX-2 inhibitors will lead most clinicians to relegate the remaining agents (celecoxib and valdecoxib) to second line status. There may still be a role for COX-2 inhibitors (especially when
used short-term in recommended doses) in patients who are at high risk for gastrointestinal bleeding, who are
at low risk for cardiovascular disease, or who do not respond to acetominophen or standard NSAIDs.
Methods Note
This scientific reference guide is a product of the Prescription Drug Information Project, a collaborative venture between the University of California and the California HealthCare Foundation. This summary is based
on a report of COX-2 inhibitor effectiveness and safety performed by the Drug Effectiveness Review Project,
that included the drugs celecoxib, rofecosib, rofecoxib, and valdecoxib. The DERP Cox-2 report is based on
a rigorous method of systematic literature reviews updated in May 2003 to ensure inclusion of relevant studies of high quality. There have been few studies that compared the different NSAIDs (including COX-2
inhibitors) directly. Another team of researchers, at the University of California, Davis, prepared a supplementary report on other drug and non-drug treatments for osteoarthritis. Both reports (DERP and UCD) were
reviewed by evaluated by a panel of highly regarded physicians and pharmacists from the University of
California and two nationally recognized outside experts. These reports are available at www.chcf.org.
Page 2
Scientific Reference Guide Osteoarthritis
(Degenerative Joint Disease)
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Median Discounted Cost Range for 30-Day Supply+
Drug Name (generic)
Cost
Low ($1 - 50)
Acetaminophen* OTC
$10
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Aspirin* OTC
$7
Diclofenac*
$27
Etodolac*
$32
Etodolac* CR
$26
Fenoprofen*
$37
Flurbiprofen*
$22
Ibuprofen*
$8
Ibuprofen* OTC
$7
Indomethacin*
$15
Indomethacin* SR
$24
Ketoprofen*
$23
Ketoprofen* CR
$47
Meclofenamate*
$33
Nabumetone*
$40
Naproxen*
$18
Naproxen* OTC
$9
Orudis KT® OTC (ketoprofin)
$7
Oxaprozin*
$38
Piroxicam*
$8
Salsalate*
$22
Sulindac*
$19
Tolmetin*
$46
Bextra® (valdecoxib)
$84
Celebrex® (celecoxib)
$80
Diclofenac CR
$75
Tolmetin DS
$60
Ponstel (mefenamic acid)
Medium ($51 - 100)
High ($101 +)
✔
✔
✔
✔
$220
* Generic
+
Average retail price available through local pharmacy chains and drugstore.com. January 2005
Note: Provides general relative cost information. Actual costs may vary widely based on how drugs are
purchased. Individual patient copay (out-of-pocket costs) may also vary greatly.
OTC is over the counter.
Brand name is listed where no generic is available.
Page 3
✔