Emerging controversies in the treatment of osteoarthritis in older individuals

To discuss emerging controversies in the treatment of osteoarthritis, particularly as they apply to older individuals.

A MEDLINE search covering articles from 1966 to July 2003 was conducted for English-language literature on clinical trials comparing nonsteroidal anti-inflammatory drugs and acetaminophen for osteoarthritis treatment. Search terms were NSAIDs, nonsteroidal anti-inflammatory drugs, osteoarthritis, and acetaminophen.

All controlled trials comparing acetaminophen and NSAIDs were reviewed.

Data from therapeutic end points comparing drugs being studied were extracted and summarized.

Early studies comparing ibuprofen and acetaminophen for knee osteoarthritis identified that therapeutic end points were similar for these two drugs. These data were the basis for clinical practice guidelines published by the American College of Rheumatology in 1995 and updated in 2000. More recent clinical trials using validated instruments to measure osteoarthritis outcomes showed that NSAIDs are better than acetaminophen. There are also recent data that showed acetaminophen is equivalent to placebo in osteoarthritis outcomes. The mean age of study subjects in all the controlled trials of NSAIDs and acetaminophen was less than 65 years, making extrapolation of data from these studies to an elderly population risky. Furthermore, use of NSAIDs in older people has more risks than acetaminophen.

Current clinical practice guidelines for osteoarthritis are based on questionable data, and new data contradicts the guideline recommendations. More studies using a geriatric population are needed to clarify if acetaminophen or NSAIDs is the better choice for initial management of osteoarthritis.