NSAIDs Worsen OA: If I Were an NSAID KOL, I'd Be Pissed...

[drusso]

NSAIDs May Worsen Arthritis Inflammation

/PRNewswire/ -- Taking anti-inflammatory pain relievers like ibuprofen and naproxen for osteoarthritis may worsen inflammation in the knee joint over time,...

www.prnewswire.com

"For the study, 277 participants from the Osteoarthritis Initiative cohort with moderate to severe osteoarthritis and sustained NSAID treatment for at least one year between baseline and four-year follow-up were included in the study and compared with a group of 793 control participants who were not treated with NSAIDs. All participants underwent 3T MRI of the knee initially and after four years. Images were scored for biomarkers of inflammation. Cartilage thickness, composition and other MRI measurements served as noninvasive biomarkers for evaluating arthritis progression. The results showed no long-term benefit of NSAID use. Joint inflammation and cartilage quality were worse at baseline in the participants taking NSAIDs, compared to the control group, and worsened at four-year follow-up."

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[gaspasser127]

“Joint inflammation and cartilage quality were worse at baseline in the participants taking NSAIDs, compared to the control group, and worsened at four-year follow-up."


I’m so tired of crappy quality studies

 

[drusso]

“Joint inflammation and cartilage quality were worse at baseline in the participants taking NSAIDs, compared to the control group, and worsened at four-year follow-up."


I’m so tired of crappy quality studies

The Bad got Worse on NSAIDs.

 

[nvrsumr]

I briefly read the press release the other day. Weird. Posited something about synovitis being protective for OA? I am not familiar with this mechanism.

Knee injection pays $60 and prp costs $25 for supplies and staff. When it’s reimbursed at $100 I’d be pissed as a cytokine kol

I kid sort of.

 

[painfree23]

Studies like this are just media grabs, I tell patients that too.

 

[Ducttape]

they were worse to start.

this study was an attempt to answer the question, and a start. i dont think we can ring death knell on NSAID based on this study though.

some concerns:

- observational study pulling patients from a database.

meaning not blinded. the control group "didnt use NSAID" - unclear how that was determined. after all, id guess 99% of Americans have a bottle of ibuprofen in their medicine cabinet.

- the researchers note that baseline cartilage quality was worse, and 4 year follow up was worse. id cant comment about how the MRI markers were determined.

- the author noted that it could be that the NSAID did not help heal but helped with pain and so those on NSAID may have been more active, leading to more injury.

- Dr. Luitjens noted that prospective, randomized studies should be performed in the future to provide conclusive evidence of the anti-inflammatory impact of NSAIDs.

 

[SSdoc33]

they were worse to start.

this study was an attempt to answer the question, and a start. i dont think we can ring death knell on NSAID based on this study though.

some concerns:

- observational study pulling patients from a database.

meaning not blinded. the control group "didnt use NSAID" - unclear how that was determined. after all, id guess 99% of Americans have a bottle of ibuprofen in their medicine cabinet.

- the researchers note that baseline cartilage quality was worse, and 4 year follow up was worse. id cant comment about how the MRI markers were determined.

- the author noted that it could be that the NSAID did not help heal but helped with pain and so those on NSAID may have been more active, leading to more injury.

can anyone give me a good reason to actually prescribe an NSAID? they are OTC. formal Rx are really no different. the patients can use them if they want

 

[specepic]

bad study

 

[Ducttape]

short term prescription so that insurance companies will approve MRI/injection/drusso's vertiflex or minuteman or SI fusion...

 

[bedrock]

can anyone give me a good reason to actually prescribe an NSAID? they are OTC. formal Rx are really no different. the patients can use them if they want

of course. celebrex and to a lesser degree mobic, which easier to tolerate from a GI perspective. This makes a big difference for some patients.

Also some patients particularly with autoimmune disease do better on more potent prescription NSAIDs such as relafen.

But for 90% of patients, I agree, OTC is just as good as a script, and I try not to write them an NSAID script.

 

[Ferrismonk]

can anyone give me a good reason to actually prescribe an NSAID? they are OTC. formal Rx are really no different. the patients can use them if they want

Two "good" reasons:

1. They will actually follow the instructions on your Rx and not take handfuls like they may with an OTC bottle.
2. Sometimes if they are Medicaid they may get it for "free" instead of paying $10 out of pocket.

That being said, I don't write Rx for NSAIDs. Not great for heart or kidneys long term.

 

[manowar rules]

Love me some meloxicam. Simple (once a day so people actually take it like they’re supposed to), cheap, got a lot of people who do well with it.

 

[SSdoc33]

Meh. Risks>benefits whenever you take them for more than a week or so.

 

[DrMDAware]

can anyone give me a good reason to actually prescribe an NSAID? they are OTC. formal Rx are really no different. the patients can use them if they want

1. Different pharmacodynamics.
2. Different penetration into joint.
3. So when you get audited the % opioids is much lower.
4. You are endorsing a multimodal strategy.

 

[deleted131481]

of course. celebrex and to a lesser degree mobic, which easier to tolerate from a GI perspective. This makes a big difference for some patients.

Also some patients particularly with autoimmune disease do better on more potent prescription NSAIDs such as relafen.

But for 90% of patients, I agree, OTC is just as good as a script, and I try not to write them an NSAID script.

I agree I like Meloxicam and celebrex due to Cox2 profile with GI/renal risk.

I write fewer NSAIDs now than when I started.

 

[afob100]

Agree with meloxicam - relatively safe. For acute radicular pain, my go to cocktail is meloxicam 7.5 mg AM and gabapentin 300-600 mg in PM.

 

[SSdoc33]

I guess if you dont prescribe opioids, you dont need to worry about meds that spare them.

The longer i practice, the less utility i see in most oral medications

 

[bedrock]

I guess if you dont prescribe opioids, you dont need to worry about meds that spare them.

The longer i practice, the less utility i see in most oral medications

Or maybe you’re not helping your patients as much as you could.

Celebrex really helps some patients, while sparing their GI tract.

 

[MitchLevi]

Not Rx'ing NSAIDS at all is dumb.

It's just one of many different tools available to us and some people do well with them.

 

[nvrsumr]

Meloxicam q am and flexeril q pm times 14 days no refills is my go to while waiting on an mri so I’m “doing something” for the patient. Might write this once a week. Not a big fan of oral meds either

 

[Ferrismonk]

Or maybe you’re not helping your patients as much as you could.

Celebrex really helps some patients, while sparing their GI tract.

I recommend Voltaren gel all the time. Spares the GI track even more.

 

[deleted875186]

I write NSAIDS all the time. Counsel about risks, tell them not to combine with other NSAIDs. Some do well in them, others find it’s not that effective and we stop. Most complications I’ve seen from NSAIDs comes from years of high dose OTC ibuprofen or naproxen by the patient because no doctor ever asked how much they were taking, not from my 7.5 - 15 mg daily meloxicam. So I make a point to find out how much ibuprofen people are taking when I see them for a consult.

 

[lobelsteve]

I write NSAIDS all the time. Counsel about risks, tell them not to combine with other NSAIDs. Some do well in them, others find it’s not that effective and we stop. Most complications I’ve seen from NSAIDs comes from years of high dose OTC ibuprofen or naproxen by the patient because no doctor ever asked how much they were taking, not from my 7.5 - 15 mg daily meloxicam. So I make a point to find out how much ibuprofen people are taking when I see them for a consult.

Yet both increase risk of an MI/CVA by 31%.

 

[Welcome123]

can anyone give me a good reason to actually prescribe an NSAID? they are OTC. formal Rx are really no different. the patients can use them if they want

Patients on a budget may get costs subsidized by insurance

 

[SSdoc33]

Patients on a budget may get costs subsidized by insurance

great. that will help them pay for their dialysis and cardiac rehab

 

[MitchLevi]

great. that will help them pay for their dialysis and cardiac rehab

Be a little more hyperbolic.

 

[SSdoc33]

Be a little more hyperbolic.

 

[SSdoc33]

yes, yes, im an awful doctor for not prescribing NSAIDS. eyeroll

we write the script to make us feel like we are doing something. or make the patient feel like we are doing something. but pretty much the exact same treatment is OTC, and its a crappy treatment to begin with, who's risks outweigh the benefits.

 

[MitchLevi]

yes, yes, im an awful doctor for not prescribing NSAIDS. eyeroll

we write the script to make us feel like we are doing something. or make the patient feel like we are doing something. but pretty much the exact same treatment is OTC, and its a crappy treatment to begin with, who's risks outweigh the benefits.

Enemy of good is perfect. NSAIDs don't FIX anything, and neither does your epidural which has a higher risk than taking a few Mobic per week.

 

[SSdoc33]

Enemy of good is perfect. NSAIDs don't FIX anything, and neither does your epidural which has a higher risk than taking a few Mobic per week.

does it?

most people take the mobic daily. for years.

an nsaid PRN is fine

 

[MitchLevi]

does it?

most people take the mobic daily. for years.

an nsaid PRN is fine

You don't have to Rx it that way.

Yes, your ESI is higher risk.

 

[GoBeers]

yes, yes, im an awful doctor for not prescribing NSAIDS. eyeroll

we write the script to make us feel like we are doing something. or make the patient feel like we are doing something. but pretty much the exact same treatment is OTC, and its a crappy treatment to begin with, who's risks outweigh the benefits.

nsaids bad, opioids bad, neuropathics crap data and also bad. many interventions with crap data.

what's left?

 

[SSdoc33]

You don't have to Rx it that way.

Yes, your ESI is higher risk.

no, it isnt.

Recognizing the Risks of Chronic Nonsteroidal Anti-Inflammatory Drug Use in Older Adults

Older adults commonly take nonsteroidal anti-inflammatory drugs (NSAIDs) chronically. Studies of older adults show that chronic NSAID use increases the risk of peptic ulcer disease, acute renal failure, and stroke/myocardial infarction. Moreover, chronic ...

www.ncbi.nlm.nih.gov

FDA Drug Safety Communication

FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes (FDA Drug Safety Communication).

www.fda.gov

 

[Ducttape]

nsaids bad, opioids bad, neuropathics crap data and also bad. many interventions with crap data.

what's left?

the thing that gets drusso pissed.

 

[kstarm]

I guess if you dont prescribe opioids, you dont need to worry about meds that spare them.

The longer i practice, the less utility i see in most oral medications

I have to agree with this. I now tell many patients that I expect no more than 20-30% improvement in their symptoms with medications and that anything more than that would be an excellent result. I also frequently tell patients that "this is not something that medications are going to fix" especially when they keep wanting to try another med.

 

[Ferrismonk]

nsaids bad, opioids bad, neuropathics crap data and also bad. many interventions with crap data.

what's left?

Level 1 evidence for PRP in knees/elbows.

Takeaway, meds aren't the answer. Yes injectable steroids count as meds in my book.

 

[epidural man]

Might be a crap study but I wouldn’t be surprised if it is true.

The inflammatory cascade is a very complex symphony that is finely tuned - not sure I buy this idea that it is always pathological.

At any rate, messing up this cascade with powerful drugs over a long period of time likely has deleterious consequences.

 

[MitchLevi]

no, it isnt.

Recognizing the Risks of Chronic Nonsteroidal Anti-Inflammatory Drug Use in Older Adults

Older adults commonly take nonsteroidal anti-inflammatory drugs (NSAIDs) chronically. Studies of older adults show that chronic NSAID use increases the risk of peptic ulcer disease, acute renal failure, and stroke/myocardial infarction. Moreover, chronic ...

www.ncbi.nlm.nih.gov

FDA Drug Safety Communication

FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes (FDA Drug Safety Communication).

www.fda.gov

Don't care to try and debate you by posting articles to support my opinion.

An occasional NSAID (a few a week) is not a problem if you're not extremely old and otherwise healthy.

 

[drusso]

the thing that gets drusso pissed.

Traditional Medicine's Approach to Treating Knee Arthritis is Blowing Up - Regenexx

Regenexx offers non-surgical, regenerative orthopedic treatment options for pain related to osteoarthritis, joint injuries, overuse conditions, spine pain, and common sports injuries.

regenexx.com

"Many physicians have been using NSAIDs and knee steroid injections for their whole careers. Because both seem to help their patients function and they are covered by insurance, they have become the standard of care. However, as the research on harm has increased, in particular with steroid knee injections, some physicians have begun to question their use and have begun offering alternatives like HA and PRP. However, on the other end of that spectrum, there is a group of physicians who don’t like being told that what they have been doing is causing harm and that they should do something else. Call it institutional momentum."

 

[SSdoc33]

Traditional Medicine's Approach to Treating Knee Arthritis is Blowing Up - Regenexx

Regenexx offers non-surgical, regenerative orthopedic treatment options for pain related to osteoarthritis, joint injuries, overuse conditions, spine pain, and common sports injuries.

regenexx.com

"Many physicians have been using NSAIDs and knee steroid injections for their whole careers. Because both seem to help their patients function and they are covered by insurance, they have become the standard of care. However, as the research on harm has increased, in particular with steroid knee injections, some physicians have begun to question their use and have begun offering alternatives like HA and PRP. However, on the other end of that spectrum, there is a group of physicians who don’t like being told that what they have been doing is causing harm and that they should do something else. Call it institutional momentum."

sigh.

i think id rather listen to Dan Bongino than Chris Centeno

 

[drusso]

sigh.

i think id rather listen to Dan Bongino than Chris Centeno

Abstract
Background
Knee osteoarthritis is a disabling disease that costs billions of dollars to treat. Corticosteroid gives varying pain relief and costs $12 per injection, whereas ketorolac costs $2 per injection, per institutional costs. The aim of this study was to compare ketorolac with corticosteroid based on pain relief using patient outcome measures and cost data.

Methods
A total of 35 patients were randomized to ketorolac or corticosteroid intra-articular knee injection in a double-blind, prospective study. Follow-up was 24 weeks. Osteoarthritis was evaluated using Kellgren–Lawrence grading. Visual analog scale (VAS) was the primary outcome measure. A query of the institutional database was performed for International Classification of Diseases, Ninth Revision codes 715.16 and 719.46, and procedure code 20610 over a 3-year period. Two-way, repeated measures analysis of variance and Spearman rank correlation were used for statistical analysis.

Results
Mean VAS for ketorolac and corticosteroid decreased significantly from baseline at 2 weeks, 6.3-4.6 and 5.2-3.6, respectively and remained decreased for 24 weeks. There was no correlation between VAS and demographics within treatments. There were 220, 602, and 405 injections performed on patients with the International Classification of Diseases, Ninth Revision codes 715.16 and 719.46 during 2013, 2014, and 2015, respectively. The cost savings per year using ketorolac instead of corticosteroid would be $2259.40, $6182.54, and $4159.35 for 2013, 2014, and 2015, respectively, with a total savings of $12,601.29 over this period.

Conclusion
Pain relief was similar between ketorolac and corticosteroid injections. Ketorolac knee injection is safe and effective with a cost savings percentage difference of 143% when compared with corticosteroid.

 

[SSdoc33]

View attachment 362669

Abstract
Background
Knee osteoarthritis is a disabling disease that costs billions of dollars to treat. Corticosteroid gives varying pain relief and costs $12 per injection, whereas ketorolac costs $2 per injection, per institutional costs. The aim of this study was to compare ketorolac with corticosteroid based on pain relief using patient outcome measures and cost data.

Methods
A total of 35 patients were randomized to ketorolac or corticosteroid intra-articular knee injection in a double-blind, prospective study. Follow-up was 24 weeks. Osteoarthritis was evaluated using Kellgren–Lawrence grading. Visual analog scale (VAS) was the primary outcome measure. A query of the institutional database was performed for International Classification of Diseases, Ninth Revision codes 715.16 and 719.46, and procedure code 20610 over a 3-year period. Two-way, repeated measures analysis of variance and Spearman rank correlation were used for statistical analysis.

Results
Mean VAS for ketorolac and corticosteroid decreased significantly from baseline at 2 weeks, 6.3-4.6 and 5.2-3.6, respectively and remained decreased for 24 weeks. There was no correlation between VAS and demographics within treatments. There were 220, 602, and 405 injections performed on patients with the International Classification of Diseases, Ninth Revision codes 715.16 and 719.46 during 2013, 2014, and 2015, respectively. The cost savings per year using ketorolac instead of corticosteroid would be $2259.40, $6182.54, and $4159.35 for 2013, 2014, and 2015, respectively, with a total savings of $12,601.29 over this period.

Conclusion
Pain relief was similar between ketorolac and corticosteroid injections. Ketorolac knee injection is safe and effective with a cost savings percentage difference of 143% when compared with corticosteroid.

? steroids are dirt cheap. this is stupid

 

[Ferrismonk]

ICD-9 and 20610? Had to go and look at the publish date.

 

[lobelsteve]

? steroids are dirt cheap. this is stupid

Zilretta. Got some in my knee. Feeling better.

 

[painfree23]

Zilretta. Got some in my knee. Feeling better.

Approved by insurance??

 

[lobelsteve]

Approved by insurance??

Self pay. Self administration

 

[Ferrismonk]

Zilretta. Got some in my knee. Feeling better.

Feeling better, but probably worsening OA.

 

[MitchLevi]

Why would you shoot Zilretta in your knee when you could PRP it first, and if that doesn't work do visco before CSI.

 

[deleted875186]

I would do a single steroid injection, some people do quite well after a single steroid. Easy to just pick up the medicine and inject it.

 

[DrMDAware]

Why would you shoot Zilretta in your knee when you could PRP it first, and if that doesn't work do visco before CSI.

valid and fair questions.

What are your talking points for people on limited incomes in regard to paying cash for PRP? Not trying to be argumentative here. Genuinely curious on how you discuss it with them.

I thought PRP was better for mild OA and younger patients. I could be wrong. Not sure where that leaves elderly patients, obese patients, those on Medicare, and/or those with severe OA.

I thought there was no difference bw HA and steroid, right? So your point is the latter has more side effects so go with the former, yeah?

I need to look up billing for HA vs steroid injections - are they that different for Medicare and commercial patients?