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96 Arthritis
NSAIDs may be safer than, while achieving similar efficacy to, nonselective
NSAIDs such as indomethacin. 5,7,8
Some illustrative NSAID studies demonstrate utility of this class in arthritis
pain. An RCT has shown that once-daily administration of the COX-2 select-
ive NSAID lumiracoxib (400 mg PO) provides pain relief comparable to that
achieved with thrice-daily indomethacin (50 mg per dose). 9 Similar results
were reported in a trial of etoricoxib (120 mg PO QD), which demonstrated the
COX-2 selective NSAID to be as effective as indomethacin (50 mg PO TID). 10
In both trials, the COX-2 selective NSAIDs were found to have significantly
fewer adverse drug events than the nonselective NSAID.
The cardiovascular risks associated with even brief use of COX-2 selective
NSAIDs are not to be ignored by the acute care provider. Emergency physi-
cians should generally try to avoid the controversy surrounding risks of COX-2
selective NSAIDs by choosing another therapeutic approach. However, the
arthritis population may include patients for whom risk profiles of COX-2
selective NSAIDs are preferable to those of nonselective NSAIDs. While the
ED physician should prescribe COX-2 selective NSAIDs only after careful
consideration, it is incorrect to assume that the current state of the evidence
refutes any short-term ED role for these agents. 11,12 The cardiovascular risks
will often be the most prominent concern, but arthritis patients are also likely
to be at increased risk from other well-known adverse effects (e.g. GI complications).
1 The question remains unresolved. Until more concrete data are
available, the ED provider should individualize therapy, taking into consideration
the planned treatment duration as well as the patient’s GIandcardiovascular
risk profiles. Some experts recommend prescribing a nonselective
NSAID with a gastroprotective agent (proton pump inhibitor), as a costbeneficial
means to provide pain relief with acceptable risk profile. However,
these reviews also concluded that there remains a role for COX-2 selective
NSAIDs in patients with higher GI risk, and lower cardiovascular risk. 13
Comparisons of parenteral versus PO NSAIDs fail to identify an advantage
to the former route. An RCT found equal efficacy between pain relief from a
dose of IM ketorolac (60 mg) or one of PO indomethacin (50 mg). 14
Corticosteroids are generally rated as a second-line therapy for crystalrelated
arthritis, although some experts feel they are equally efficacious as