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What is the first line therapy for osteoarthritis and the mechanism of action?
Osteoarthritis (OA) is one of the most common painful musculoskeletal conditions. Osteoarthritis typically affects the knee and hip joints in older patients. The goal of OA treatment is to relieve pain and improve function without causing harm to the patient (Jarrel & Perriman, 2022). If pharmacological treatment is recommended, topical treatments are generally considered the first-line therapy for hand and knee OA (Arcangelo et al., 2021, p. 649). However, for all forms of OA, oral non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy and are preferred to opioids and acetaminophen due to better-proven efficacy and more favorable side effects profile (Arcangelo et al., 2021, p. 649). However, the selection is challenged by several factors, including the patient’s age, comorbidities, and polypharmacy. NSAIDs are a chemically heterogeneous group of agents that inhibit the production of prostaglandins (PG) and thromboxane A through the blockade of cyclooxygenase (COX) (Magni et al., 2021). A study performed (Magni et al., 2021) concluded that diclofenac at 150 mg/ day is the best NSAID in pain and function amelioration in OA, superior to the maximum doses of frequently used NSAIDS, including ibuprofen, naproxen and celecoxib.
Benefits and risks of celecoxib (Celebrex)
Celecoxib (Celebrex) was the first coxib introduced into clinical practice; it is effective for symptomatic treatment as conventional NSAIDs and some other coxibs and can significantly reduce upper gastrointestinal events (Cheng et al., 2021). However, the subsequent coxib, rofecoxib, increased cardiovascular events. Cardiovascular safety on NSAIDs is highly controversial. One hypothesis is that coxibs impact vasoactive endothelium-derived factors, mainly inhibiting prostaglandin synthesis, which is essential for regulating vascular tone and sodium excretion and may influence blood pressure, but it is not sure yet. Nevertheless, according to Cheng et al. (2021) celecoxib does not significantly increase cardiovascular events compared to placebo and slightly decreases the risk of all-cause mortality and cardiovascular mortality compared with NSAIDs, which may prove it safe when used on rheumatoid arthritis and osteoarthritis patients.
Ibuprofen and celecoxib
In a study performed (Gordo et al., 2017), they found that celecoxib was well tolerated compared to placebo and ibuprofen, and the proportion of patients with an upper gastrointestinal event was higher with ibuprofen than with celecoxib. Celecoxib is an alternative for patients experiencing gastrointestinal (GI) adverse effects; this is also an option for patients with GI comorbidities such as a history of ulcer disease (Arcangelo et al., 2021, p. 650). On the other hand, oral non-selective NSAIDs such as ibuprofen can also be used for patients without risk factors for GI disturbances. Alternatively, the use of a non-selective NSAID along with a proton pump inhibitor may be sufficient to provide analgesia along with gastric protection.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V. F., & Kang, T. M. (2021). Pharmacotherapeutics for advanced practice (5th ed.). Wolters Kluwer Health.
Cheng, B., Chen, J., Zhang, X., Gao, Q., Li, W., Yan, L., Zhang, Y., Wu, C., Xing, J., & Liu, J. (2021). Cardiovascular safety of celecoxib in rheumatoid arthritis and osteoarthritis patients: A systematic review and meta-analysis. PLOS ONE, 16(12), e0261239. /orders/doi.org/10.1371/journal.pone.0261239
Gordo, A. C., Walker, C., Armada, B., & Zhou, D. (2017). Efficacy of celecoxib versus ibuprofen for the treatment of patients with osteoarthritis of the knee: A randomized double-blind, non-inferiority trial. Journal of International Medical Research, 45(1), 59–74. /orders/doi.org/10.1177/0300060516673707
Jarrel, L., & Perriman, L. K. (2022). Topical NSAIDs as First-Line Treatment for Mild to Moderate Osteoarthritis. Clinical Advisor, NA. /orders/link.gale.com/apps/doc/A701326019/AONE?u=stu_main&sid=ebsco&xid=ee7e0c3c
Magni, A., Agostoni, P., Bonezzi, C., Massazza, G., Menè, P., Savarino, V., & Fornasari, D. (2021). Management of osteoarthritis: Expert opinion on nsaids. Pain and Therapy, 10(2), 783–808. /orders/doi.org/10.1007/s40122-021-00260-1
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