Practical considerations for the pharmacologic management of osteoarthritis

Pharmacologic treatment options for osteoarthritis (OA) are diverse both in terms of mechanisms of action and delivery formulations; however, no single agent has been demonstrated to consistently offer both a high level of tolerability and a sustained degree of efficacy across a broad OA patient population. Ultimately, a multimodal approach to OA treatment is the best option, offering a greater likelihood of tolerability by avoiding sustained exposure to higher risk agents while improving efficacy by combining agents with more than one mechanism of action. Such an approach should take into consideration the compatibility of different pharmacologic therapies while also taking advantage of nonpharmacologic treatments. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), which are both easily accessible to patients and generally effective for pain relief, are the most popular pharmacologic therapies used in OA; unfortunately, these agents are associated with gastrointestinal and other cardiovascular risks. Combining these agents with other treatments possessing differing side-effect profiles and mechanisms of action will likely reduce the safety and tolerability risk. The recent availability in the United States of a topical NSAID gel with less systemic exposure than oral NSAIDs may offer clinicians an additional means of achieving effective analgesia in OA of superficial joints while minimizing the risk of adverse events.