Lower doses of NSAIDs safer but still effective in OA

Lower doses of oral NSAIDs are safer to use than the maximum recommended while still providing a clinically meaningful benefit to patients with osteoarthritis, an analysis of 90 active treatment regimens has found.

The research, which included 192 trials and 102,829 participants taking NSAIDs, COX-2 inhibitors, opioids and paracetamol compared different preparations of treatments for knee and hip osteoarthritis pain and physical function to assess whether they were safe and effective at their lowest possible doses.

The findings, published in The BMJ, revealed that diclofenac 150 mg/day and etoricoxib 60 mg/day were the most effective oral NSAIDs for osteoarthritis pain. However, the researchers said their use is “probably not appropriate in the presence of comorbidities” or in the long term, “given the mild increase in the risk of adverse events for both drugs”.

Among topical treatments, diclofenac had the largest effect on pain and physical function (regardless of dose). The lowest dose (70-81 mg/day) had a 92% probability of having a minimum clinically relevant improvement on pain, with a better safety profile than oral diclofenac, and thus” should be considered as first line pharmacological treatment for knee osteoarthritis”, the researchers noted.

However, the data showed that opioids and paracetamol have “a significantly smaller effect on knee or hip osteoarthritis pain and physical function”, with an increased risk of harm compared with oral and topical NSAIDs. Even when patients receive lower doses of non-tramadol opioids, they are up to 13 times more likely to interrupt treatment due to adverse events, and up to 10 times more likely to experience any type of adverse events compared with oral placebo, the authors said.

The researchers concluded that their results showed that lower doses of oral NSAIDs “have more favourable safety profiles than maximum recommended daily doses” while still maintaining a high probability of treatment effect in the treatment of hip and knee osteoarthritis pain.

However, they also cautioned that “the potential benefits of these interventions must be carefully weighed against potential harms for each individual patient because the presence of comorbidities or long term use might increase the risk of serious adverse events.”

They also noted that physicians could use the results of their analysis “to identify the lowest doses of different drug preparations that are effective and safe when first prescribing treatment, as generally recommended by current clinical practice guidelines.”

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