Nonsteroidal therapy of rheumatoid arthritis and osteoarthritis: how physicians manage treatment failures

Few studies have examined the practice patterns of primary care physicians who treat patients with rheumatoid (RA) or osteoarthritis (OA), and the strategies used when nonsteroidal antiinflammatory drugs (NSAID) are ineffective or cause side effects. Our purpose was to study practice patterns of physicians who initiate treatment of RA and OA, and their management approaches when NSAID are ineffective or cause dyspepsia.

Using a structured questionnaire simulating management of patients with RA or OA we surveyed treatment preferences of primary care physicians.

Responses from 176 physicians were analyzed. For RA 98% used NSAID as initial therapy. For those patients who did not respond, most (over 60%) would either change or increase the initial NSAID and try a mean of 2.2 different NSAID over a period of 3.3 months before initiating second-line therapy or referring to a rheumatologist. For OA 67% of physicians surveyed initially used NSAID to treat these patients, and changing or increasing the NSAID was the most common strategy used to manage patients not responding to initial therapy. For patients who developed dyspepsia taking NSAID there was wide divergence of management approaches in both diseases: stopping the NSAID and starting an analgesic (OA) or second-line agent (RA) were common choices, but continuing the NSAID and adding an "antidyspeptic" regimen was chosen by over half of physicians selecting a single regimen. Most initial management approaches did not differ significantly between RA and OA.

NSAID are used frequently as initial therapy in patients with OA, and in RA the initiation of second-line therapy is often deferred for months and is only prescribed after patients have failed several NSAID. Opportunities exist to better standardize the approaches physicians use in the initial management of RA and OA, and to delineate what role NSAID should have in the management program of these disorders.