Are Anti-Inflammatory Medications Safe for Osteoarthritis Sufferers?
Much attention was given to the withdrawal of Vioxx from the marketplace when evidence of potential injury to the cardiovascular system was documented several years ago. A group of cardiologists has issued a statement suggesting that opiate analgesics may be preferable to nonsteroidals (anti-inflammatory medications used routinely in osteoarthritis and other forms of inflammatory arthritis), and this has generated much controversy within the rheumatology community.
A recent publication in Osteoarthritis and Cartilage looked at the efficacy and safety of opioids for treatment of osteoarthritis. The authors recognize the utility of routine Tylenol and anti-inflammatories in the management of osteoarthritis, conceding that Tylenol is often ineffective (even in high doses) for osteoarthritis pain, and that the side effects of conventional nonsteroidals (most prominently gastrointestinal bleeding and kidney impairment) may outweigh their benefits. Against this background, opioid analgesics are frequently recommended for patients with severe osteoarthritis pain, anticipating early joint replacement for those who do not (or cannot) continue on analgesic therapy. The study was designed to address whether opiates are effective in treating osteoarthritis pain, and secondarily whether opiates improved physical function in patients with osteoarthritis.
This publication looked at 18 randomized, controlled studies looking at the safety and effectiveness of opioids compared with placebo or conventional anti-inflammatory medications in patients with osteoarthritis. Over 3000 patients received opiate therapy, and over 1500 patients received placebo with a mean age of 61 and 62 years in both treatment and placebo groups. Opiates were far more effective in treating both pain and improving physical function in patients with osteoarthritis. There was a significant increase in side effects from opiate use compared to placebo (most common was nausea followed by constipation and dizziness). Even so, these side effects were reversible upon discontinuation of therapy, Direct comparison of opiates with nonopiate analgesics was performed in only several studies, not allowing meaningful comparison to be made.
The authors concluded that opioids significantly reduce pain intensity in patients with osteoarthritis, improving physical function to a minor degree (especially when compared to placebo drugs). The frequency of adverse side effects, specifically nausea, constipation and dizziness, may preclude their use in selected patients in clinical practice. Rheumatologists will continue to use opiates sparingly, preferring to choose less potentially toxic agents either as single medications or in combination to achieve pain relief without adverse consequence. As always, the decision regarding which medications are used in specific clinical conditions is reserved for the interaction between patient and treating rheumatologists alone.