Naproxen or ibuprofen—obtained over the counter or by prescription—provide more benefit for older adults who have knee osteoarthritis (OA) plus co-existing conditions compared to more expensive, prescription-only pain medications, according to a study funded by the NIH’s National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). The study was published in the journal Osteoarthritis and Cartilage.
Older adults with knee OA typically are given acetaminophen as a first line of treatment, and eventually progress to non-steroidal anti-inflammatory drugs (NSAIDS) such as naproxen or ibuprofen. They may also use topical agents or undergo corticosteroid injections. Stronger prescription-only NSAIDS such as celecoxib, and opioids such as tramadol, also may be used. However, celecoxib is associated with cardiac risks, and tramadol, although considered safer than other opioids, can be toxic or lead to dependence. Knee OA can become more difficult to manage in older patients with co-existing illnesses such as cardiovascular disease and diabetes, because use of certain NSAIDS or opioids can heighten the risk for complications. Despite these concerns, the rate at which opioids are prescribed for knee OA has been climbing.
"Managing knee OA pain in older adults with co-existing health concerns can be costly and requires a delicate balance between pain relief and toxicity," said NIAMS grantee and author Elena Losina, Ph.D., of Brigham and Women’s Hospital in Boston. "We aimed to clarify the best treatment approach, keeping in mind both the need for positive outcomes as well as cost-effectiveness."
To examine the issue, the researchers employed the Osteoarthritis Policy Model, which simulates the natural history and management of knee OA. The model uses demographic and clinical characteristics typical of older adults with knee OA, including the occurrence of common co-existing diseases, to predict outcomes.
The investigators compared health outcomes and cost effectiveness of multiple treatment strategies, including:
- Naproxen-based strategies, including naproxen plus a proton pump inhibitor (PPI) to ease gastrointestinal upset
- Ibuprofen-based strategies, including ibuprofen plus a PPI
- Celecoxib strategies, including celecoxib plus a PPI
The study found that for older people with knee OA, diabetes, and heart disease, the naproxen-based treatments—with or without a PPI—were more cost effective than tramadol and celecoxib. In addition, naproxen use was associated with lower rates of cardiac risks compared to celecoxib, and lower rates of toxicity and treatment discontinuation compared to tramadol, suggesting a better clinical outcome. Ibuprofen-based treatments showed similar outcomes as naproxen-based treatments.
"Doctors often switch from medication to medication to find the right fit for a patient. These findings may help them prioritize treatment choices, and juggle key considerations for each patient," said Dr. Losina. "In addition, we should limit tramadol use in these older OA patients with multiple diseases."
This work was supported by the NIH’s NIAMS (grants R01-AR064320 and K24-AR057827).
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Cost-effectiveness of nonsteroidal anti-inflammatory drugs and opioids in the treatment of knee osteoarthritis in older patients with multiple comorbidities. Katz JN, Smith SR, Collins JE, Solomon DH, Jordan JM, Hunter DJ, Suter LG, Yelin E, Paltiel AD, Losina E. Osteoarthritis and Cartilage. 2016 Mar;24(3):409-18. Doi: 10.1016/j.joca.2015.10.006. PMID: 26525846.