Dr. Balmaceda notes that while the data sources may be identical, their interpretation by expert panels may vary — age may be a more relevant factor in guidelines produced by the American Geriatrics Society than those developed by the international Osteoarthritis Research Society.
In contrast, the NICE guidelines, which are currently the most supportive of topical NSAIDs in the setting of hand and knee OA, were developed by physicians and other healthcare professionals working in conjunction with a range of clinical researchers.
Guidelines are also limited by the research and agents available at the time they were developed, Dr. Balmaceda writes. American Pain Society guidelines, which do not recommend any topical NSAIDs for OA, were published before the FDA had approved any such treatments.
Despite somewhat conflicting recommendations regarding their use, the safety and efficacy of topical NSAIDs was apparent in the overall literature, including reports published after many of the available guidelines were released.
“In studies, topical NSAIDs have shown non-inferiority to oral NSAIDs and have a superior safety profile. Thus, in our opinion, they may be the preferred first-line treatment option for any patient with knee or hand OA,” Dr. Rannou said.
“[Topical NSAIDs] should especially be considered for older adults, those with comorbidities, and those at an increased risk of cardiovascular, gastrointestinal, or renal side effects because they avoid the systemic adverse effects of oral NSAIDs that can be especially problematic for these patient populations,” Dr. Rannou emphasized.
Patient Selection is Key
Topical NSAIDs reduce the risk for severe adverse effects by confining drug activity to the application site, thereby limiting systemic exposure. Accordingly, these agents cannot penetrate into deeper-lying joints and should be reserved for joints that are closer to the surface, such those of the knee and hand, Dr. Rannou pointed out, noting that nightly treatments have proven effective for long-term pain control in his patients.
Patient selection is important, concurs Steven R. Gambert, MD, AGSF, MACP, from the division of gerontology and geriatric medicine at the University of Maryland Medical Center in Baltimore, MD,
“When bone rubs on bone, as frequently occurs in someone with significant OA, topical NSAIDS likely will not be sufficient for pain relief,” Dr. Gambert told Clinical Pain Advisor. Still, studies suggest that their use can reduce the need for concomitant oral NSAIDs by up to 40%.1