Osteoarthritis – Considerations in Selecting Patients for NSAID and COX-2 Therapy: Stratifying Risk in Practice

Contents

• Introduction
• Treating Chronic Pain: The NSAIDs
• Initial Pharmacologic Therapy: Acetaminophen or NSAIDs?*
• All the Facts: Acetaminophen and Safety*
• Individualizing Therapy: Differentiating NSAIDs by Safety and Efficacy*
• Mechanisms Underlying NSAID-Related Side Effects*
• COX-1 and Gastroprotection*
• GI-Sparing Pain Relief: The COX-2 Inhibitors*
• COX Inhibition and the Cardiovascular System*
• Is CV Risk a Class Effect?*
• Making Sense of the Data: Matching Patients With Appropriate Therapy*
• Stratifying Patients by GI Risk*
• Gastroprotective Strategies*
• Stratifying Patients by CV Risk*
• Anticoagulation and NSAIDs*
• Risk Stratification in Clinical Practice: Case Studies*
• Case Study 1*
• Case Study 2*
• Summary*
• References*
• Additional Information*

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Target Audience

This continuing medical education activity has been developed for physicians, nurses,
pharmacists, and other allied healthcare professionals treating osteoarthritis.

Purpose Statement

Pain is the patient complaint most frequently encountered by healthcare professionals.
Estimates of those suffering some form of chronic pain range as high as 90 million.
Although pain presents so frequently, most experts agree it is less often adequately relieved.
Osteoarthritis is the most prevalent form of arthritis in the United States affecting more
than 70% of adults between 55 and 78 years old.

(Brooks P. Inflammation as an important feature of osteoarthritis. Bull World Health Organ.
2003;81:689-690)

The purpose of this activity is to discuss considerations in selecting patients for NSAID and
COX-2 therapy.

Learning Objectives

After completing this activity, participants will be able to:

• Identify appropriate and at-risk patients for NSAID and COX-2 therapy
• Translate the data surrounding the risks and benefits of NSAID and COX-2 use to better
  match specific patients to appropriate therapy
• Develop and establish risk stratification strategies for patients in their practice

Introduction

The treatment of many chronic pain conditions, such as osteoarthritis (OA),
relies heavily on the use of nonsteroidal antiinflammatory drugs (NSAIDs).
This broad class of drugs includes some of the most widely used medications
in the United States.¹ While the NSAIDs provide control of symptoms for many
patients with OA or other chronic pain states, they are also associated with the potential
for serious side effects, including gastrointestinal (GI) and cardiovascular (CV) adverse
events.^1,2 The literature describing these side effects continues to evolve, and our understanding
of the relative benefits and risks of individual NSAIDs remains in flux. For
clinicians who treat patients with OA or other chronic pain, it is imperative to understand
how these risks translate into clinical practice. This tutorial discusses risk stratification
strategies for the use of NSAIDs in patients with chronic pain.

Treating Chronic Pain: The NSAIDs

Options for the treatment of chronic pain associated with OA include nonpharmacological
interventions—such as physiotherapy, appropriate exercise, weight reduction, and the use
of assistive devices—and a range of pharmaceutical agents (Table 1).³ Nonpharmacologic
measures should be initiated first, and continued throughout the course of treatment. For
many patients, however, these measures may not provide adequate symptom control.³
Initial pharmacological therapy, as described by the American College of Rheumatology
(ACR) recommendations for the management of OA, may include the use of simple
analgesics, such as acetaminophen. When symptoms do not respond sufficiently to
acetaminophen, an NSAID may be considered.³ This class of drugs includes both traditional,
or nonselective agents, and the selective cyclooxygenase-2 (COX-2) inhibitors.

Overall, the NSAIDs are the most widely used medications in the United States.¹ This
popularity is rooted in their effectiveness and relative safety, which is due to the
antiinflammatory effect in addition to the analgesic properties. Surveys of patients
with OA and other chronic pain, for example, have demonstrated a clear preference for
NSAIDs over acetaminophen.^4,5 And a meta-analysis of clinical trial data supports the
survey findings. In this analysis, NSAIDs reduced rest and walking pain due to OA to a
significantly greater extent than acetaminophen.⁶

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