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Musculoskeletal pain

Musculoskeletal pain. NSAIDs, analgesics and non-drug approaches. Targeting treatment in OA. Other pharmaceutical options. Core Treatments. Other non-drug treatments. Self-management techniques. Relatively safe pharmaceutical options. Surgery.

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Musculoskeletal pain

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  1. Musculoskeletal pain NSAIDs, analgesics and non-drug approaches

  2. Targeting treatment in OA Other pharmaceutical options Core Treatments Other non-drug treatments Self-management techniques Relatively safe pharmaceutical options Surgery NICE Clinical Guideline 59:Osteoarthritis, Feb 2008

  3. Houston, we have a problem…(1)MeReC Extra Issue 30. November 2007 • All NSAIDscarry a risk of GI side effects • Risk increases with age, presence of comorbidities and dose of NSAID • Coxibshave a lower GI risk than traditional NSAIDs • Dyspepsia can still occur and may be as common as with traditional NSAIDs • Severe and sometimes fatal GI reactions can occur • Benefits diminished when co-administered with aspirin • Low-dose ibuprofen has a lower GI risk than diclofenac and naproxen • Using a PPI significantly reduces the risk of serious GI adverse effects and dyspepsia with any NSAID • No good evidence that adding a PPI to a coxib is more beneficial than adding a PPI to a traditional NSAID

  4. Houston, we have a problem…(2)MeReC Extra Issue 30. November 2007 • Coxibs cause a small increased absolute risk of thrombotic events compared with placebo • The excess risk is estimated to be about 3 cases per 1000 users treated for 1 year on average • This risk increases with dose and persists throughout treatment • All coxibs are contraindicated for patients with established ischaemic heart disease, peripheral arterial disease and/or cerebrovascular disease • Diclofenac150mg/d has a thrombotic risk profile similar to that of the coxibs • Ibuprofen 1200mg/d and naproxen1000mg/d have a lower thrombotic risk • Cardio-renal effects seem to apply to all NSAIDs and selective COX-2 inhibitors, and contribute to CV risk

  5. CV risks? It’s a volume thing…MeReC Extra Issue 30. November 2007 • Prescribing of coxibsmay be responsible for approximately 240additional or premature CV events per year in England alone • Approximately 2000additional or premature CV events per year could be caused by diclofenac prescribing NSAID prescribing in England April to June 2007: % total items (4.3 million)

  6. What do we need to consider? For the individual patient there will be a trade-off along each of these dimensions Cardiovascular risks Symptoms and response to treatment Gastrointestinal risks

  7. So, what’s the deal? For patients taking NSAIDs which carry a higher CV risk: • Switching to paracetamol 4g/day • Will reduce cardiovascular risk • Will reduce gastrointestinal risk • Efficacy? • Switching to ibuprofen 1200mg/day • Will reduce cardiovascular risk • Will reduce gastrointestinal risk (especially if use a PPI as well) • Efficacy? • Switching to naproxen 1g/day • Will reduce cardiovascular risk • May increase gastrointestinal risk (but what about using a PPI?) • Efficacy?

  8. Trends in naproxen and diclofenac prescribing in England pre-and post-NPC NSAID initiatives

  9. Change in NSAID prescribing(6-month periods a year apart)

  10. Who should we prioritise for review? • People at high GI risk • Age >65 years • History of GI bleeding, ulcer or perforation • Those taking medicines that increase risk of upper-GI AEs (eg warfarin, aspirinand corticosteroids) • Serious comorbidity, eg CV disease, renal or hepatic impairment, diabetes or hypertension • Prolonged duration or maximum doses of NSAID • Excessive alcohol use • Heavy smoking • People at high CV risk • Those with established CVD • Those taking CV medication, especially aspirin and clopidogrel • Older men • Smokers • People with diabetes • Some risk factors increase both CV and GI risk — people with these need particular attention

  11. Three steps to NSAID heavenTM • Don’t use them unless you have to • The only way to avoid NSAID side effects is not to use them • Paracetamol works for many • Employ non-drug interventions routinely • Consider topical NSAIDs ahead of oral NSAIDs for OA • If you have to use them, use them wisely • The balance of benefits and risks needs to be carefully assessed; think about CV, GI and renal issues routinely • Use a safer drug (ibuprofen, then naproxen) in the lowest effective dose for the shortest period • NSAID users should be a high priority for medication review: are NSAIDs effective/needed? Drug holidays? Don’t issue repeat prescriptions without review • Consider gastroprotection in those at high risk • Options are PPIs, double-dose H2RAs, misoprostol • Co-prescribe PPI with NSAID for OA All of this particularly applies to those aged over 65 years

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