Recommendations on the Use of NSAIDs in Osteoarthritis
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The preponderance of scientific evidence shows that NSAIDs damage articular cartilage. Various scientific papers and consensus groups have stated that there is no convincing data to show that the widely used NSAIDs and recommended selective COX-2 inhibitors have favorable effects on cartilage.129-131 Even the main consensus paper from the International Cartilage Repair Society and Osteoarthritis Research Society International stated that NSAID use has to be limited to the short term. Specifically the recommendation was as follows: In patients with symptomatic hip or knee osteoarthritis, non-steroidal anti-inflammatory drugs (NSAIDs) should be used at the lowest effective dose but their long-term use should be avoided if possible.132 They also noted that NSAIDs should not be first-line therapy for joint OA. Other groups have raised similar sentiments. The committees of the International League Against Rheumatism and the World Health Organization came up with guidelines for the testing of new drugs in osteoarthritis. The consensus from these meetings resulted in recommendations by The European Group for the Respect of Ethics and Excellence in Science (GREES) for governmental registration and approval of new drugs used in the treatment of OA and have added the requirement that the drug not have a deleterious effect on the diseased and non-diseased contra lateral joint; i.e., no deleterious effect on osteoarthritic or normal cartilage.133 If this latter recommendation were followed, the vast majority, if not all NSAIDs, would be immediately taken off the market and no new ones would get approved.
While it is admirable for the various consensus and rheumatology organizations to educate doctors and the lay public about the necessity to limit NSAID use in OA, this author (RH) feels the warnings are not enough. Within the last year, for instance, the FDA has again implemented new rules requiring stronger and more extensive label warnings (in addition to the heart disease risks) regarding the risk of liver damage and stomach bleeding for people taking common over-the-counter pain relievers. As for NSAIDs, the new regulations require front labels to instruct users to see new warnings that say, “This product contains a nonsteroidal anti-inflammatory drug (NSAID), which may cause severe stomach bleeding. The chance is higher if you are age 60 or older, have had stomach ulcers or bleeding problems, take a blood thinning or steroid drug, take other drugs containing prescription or nonprescription NSAIDs, have three or more alcoholic drinks every day using this product, take more or for a longer time than directed.”134
The lay public for whom NSAIDs are prescribed and recommended by both health care professionals and drug manufacturers should be aware that long-term NSAID use is detrimental to articular cartilage. Specifically, be informed that NSAIDs will likely worsen the OA disease for which it is prescribed. Physicians, allied health care professionals, and drug manufacturers should be required to inform the lay public that NSAID use can accelerate OA articular cartilage degeneration. A strict warning label on these medications should read as follows:
The use of this nonsteroidal anti-inflammatory medication has been shown in scientific studies to accelerate the articular cartilage breakdown in osteoarthritis. Use of this product poses a significant risk in accelerating osteoarthritis joint breakdown. Anyone using this product for the the pain of osteoarthritis should be under a doctor’s care and use of this product should be with the very lowest dose and for the shortest possible duration of time.
One of the basic tenants of medicine is stated in the Hippocratic oath, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”135 For doctors to uphold this statement in the treatment of their OA patients, it would necessitate the almost complete banning of the use of NSAIDs for this condition. If this does not occur, then most likely the exponential rise in degenerative arthritis and subsequent musculoskeletal surgeries, including knee and hip replacements, as well as spine surgeries, will continue for decades to come.
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