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Arthritis 99
achieved in a third of treated patients. 32 Although the acute care implications
are uncertain, and clinicians should keep in mind the potential for systemic
absorption and related side effect risk, large-scale meta-analyses consistently
suggest a useful role in topical NSAIDs for OA therapy. 25,33,34 For the most
part, these topical agents are probably best left to the longitudinal care
provider, but there may be instances (e.g. when topical agents have previously
been effective) when ED prescription is appropriate.
Both clinical experience and the available trial evidence reflect a growing
emphasis on use of COX-2 selective NSAIDs for treating OA (owing to the
improved GI side effect profile compared with nonspecific NSAIDs). 35,36 As
noted above in the discussion on crystal arthropathies, the potential cardiovascular
side effects of the COX-2 selective NSAIDs cannot be dismissed. 11
However, both meta-analysis (including OA patients and others) and individual
OA trials underscore arguments that acute care clinicians should not
allow cardiovascular risk concerns to blunt awareness of NSAIDs’ GI effects. 12
A large-scale RCT, for example, found similarly low cardiovascular side
effects and equivalent pain relief in OA patients taking celecoxib (100 mg
PO BID) as taking diclofenac (50 mg PO BID) or naproxen (500 mg PO BID);
the COX-2 selective NSAID was also found to have significantly fewer GI
effects. 37 Similarly, pooled analysis of thrombotic cardiovascular events
from multiple clinical trials of the COX-2 selective NSAID agent etoricoxib
failed to identify a significant risk over that associated with nonselective
NSAIDs. 38 Even after considering the recently delineated risks of the COX-2
selective NSAIDs, a recent expert panel review concluded that available
evidence supported use of this class for treating OA. 39
A randomized double-blind investigation reported that the COX-2 selective
NSAIDs valdecoxib (10 mg PO QD) and rofecoxib (2.5 mg PO QD) both
achieve significantly better pain relief than placebo in as little as 3 h after oral
administration. 40 Trials generally indicate little analgesic difference between
various COX-2 selective NSAIDs. Though the literature on the subject continues
to evolve, it is unlikely that, as a class, the COX-2 selective NSAIDs
consistently provide better analgesia than do the nonselective NSAIDs. For
instance, meta-analysis and well-conducted RCTs have demonstrated that
lumaricoxib (100 mg PO QD) relieves pain at least as well as celecoxib,