Osteo-arthritis (OA) treatment involves the use of analgesics to reduce the severity of the symptoms allowing patients to get on with their normal life.  

Dosage regimen

• Paracetamol 1g four times daily.

   

• Topical NSAIDs have been shown to be particularly useful for knee or hand OA and should be used before considering oral NSAIDs or opioids.

   

• Oral NSAIDs are usually given in divided doses throughout the day, preferably with or after food. Refer to the individual SPC for further details.

   

• Opioids Codeine should be tried first and used when required in addition to regular paracetamol or NSAIDs.

   

• Topical capsaicin A small amount (pea size) should be applied topically three to four times daily.

Patient's knowledge of the medicine's use

• Is the patient aware that the medicines only provide symptomatic relief and do not cure the underlying condition?

Is the medication working?

• Does the patient feel that his or her condition is well controlled, or is it getting worse?

   

• Paracetamol is more effective used on a regular basis instead of being reserved for a painful flare-up.

   

• Capsaicin can provide some pain relief within the first week of treatment, although it can take a number of weeks before the full effects are seen.

   

• Is the patient following appropriate lifestyle advice, in combination with medications?

Side effects

Paracetamol At recommended doses, there is a low risk of adverse events and side effects are rare. Patients should be warned against taking other paracetamol-containing preparations eg for colds and flu.

NSAIDs commonly cause GI related side effects such as nausea and diarrhoea. Patients presenting with suspected GI bleeding or ulceration should be referred. PPI prophylaxis should be considered in all patients, especially those taking regular NSAIDs, patients over 65 years and anyone with a history of peptic ulcer disease or GI complications. Ibuprofen has been shown to carry the lowest risk of GI side effects. There is an increased risk of thrombotic events (stroke, myocardial infarction) especially with the COX-2 inhibitors. However non-selective NSAIDs have also been associated with an increased risk, particularly when used long term or in high doses. Oral NSAIDs and COX-2 inhibitors should be used at the minimum effective dose and for the shortest period possible.

Topical NSAIDs generally have a better safety profile than their oral equivalents. They may cause local skin irritation and should not be used on inflamed or broken skin. Frequent or excessive application may result in systemic effects.

Opioids The most common side effects include nausea, vomiting, dry mouth and constipation. The patient may need laxatives if taking opioids on a regular basis. Drowsiness can be a major problem; patients should be counselled to avoid alcoholic drinks and take care when driving, especially if the medication is newly prescribed or the dose has been increased.

Capsaicin can cause a transient burning sensation, which is made worse by showering or having a hot bath before application. Avoid contact with the eyes and broken or inflamed skin.

Monitoring

Patients on NSAIDs should be monitored on a frequent basis to review whether the benefit of treatment outweighs any side effects or risks associated with treatment.

Lifestyle

• Low impact exercise is an essential component in the management of OA and the patient should be given weight loss advice if appropriate. 

   

• Applying heat to the affected joint can provide relief from the pain and the stiffness associated with OA.

   

• Glucosamine and chondroitin are widely used, although evidence on their effectiveness is mixed.

 Andrew Sturrock is a hospital pharmacist from Gateshead.

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