Systemic Therapies

If physical and/or local measures do not control pain in OA, oral analgesics or NSAIDs are considered next. Systematic reviews have found that simple analgesics such as paracetamol and NSAIDs produce short-term pain relief in OA.94[I] However, there is no good evidence that NSAIDs are superior to simple analgesics such as paracetamol or that one NSAID is better than another.94[I] There is some evidence that indometacin (and possibly other NSAIDs) may accelerate progression of OA.114

In practice, most physicians treat patients with paracetamol initially and an NSAID is added if symptoms remain uncontrolled. When used, NSAIDs are prescribed in the lowest effective dose and for a short time. There is some evidence to suggest a slight benefit if dex-tropropoxyphene is added to paracetamol but at a cost of increased toxicity.115[V] An RCT of 90 patients showed that treatment of knee OA with tramadol allowed reduction of the naproxen dose among those patients with naproxen-responsive pain.116[II]

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