Therapeutic target
- Relief of symptoms
Therapy recommendations
- For non-active coxarthrosis: analgesic/pain reliever paracetamol (best tolerated) Caution! According to a meta-analysis, paracetamol is hardly effective in coxarthrosis and gonarthrosis.
- In activated coxarthrosis (abraded cartilage or bone inflamed): nonsteroidal anti-inflammatory drugs (NSAIDs), e.g., selective COX-2 inhibitors (e.g., etoricoxib) or diclofenac [no long-term therapy! ]Note: No diclofenac in cardiovascular risk! Affected are patients with heart failure (cardiac insufficiency) of NYHA classes II to IV, coronary artery disease (CAD, coronary artery disease), peripheral arterial occlusive disease (CAD) or cerebrovascular disease.
- In terms of pain and function, diclofenac – and, with slight reductions – etoricoxib work best in patients with gonarthrosis and coxarthrosis.
- If necessary, glucocorticoids; the effect of intra-articular injection (“into the joint cavity”) is controversial (EULAR guideline: 1b; OARSI guideline: suitable; AAOS guideline: not suitable), but can be administered if inflammation can not be controlled otherwise.
Further notes
- Intravenous administration (administration) does not provide advantages over oral administration.
- Continuous therapy should not be used.
- Different NSAIDs should not be combined!
- Alternative therapy for high cardiovascular/gastrointestinal risk → conventional NSAIDs + low-dose acetylsalicylic acid (ASA) + proton pump inhibitors (PPI; acid blockers) (recommendation of the Drug Commission of the German Medical Association).
- Caveat. According to a cohort study, 1-year mortality rates were significantly increased after short- to medium-term tramadol use as an analgesic in patients with osteoarthritis compared with NSAIDs (naproxen, diclofenac, celecoxib, and etoricoxib). Death rates under codeine were similar to those under tramadol in a head-to-head comparison (34.6 and 32.2/1,000 person-years, respectively).
Glucocorticoids
- Mode of action: Glucocorticoids have antiphlogistic and antiedematous (anti-inflammatory and decongestant) effects.
- The effect in intraarticular injection (injection into the joint cavity) is controversial (EULAR guideline: 1b; OARSI guideline: suitable; AAOS guideline: not suitable), but can be administered in cases of inflammation that cannot be controlled otherwise.
- Note: Intra-articular corticosteroid injection (administration of glucocorticoids into the joint cavity) is likely to cause joint damage. This is suggested by the following radiologic findings:
- Rapid narrowing of the joint space (rapid progressive osteoarthrits, RPOA type 1) occurred in 6% of all participants.
- In about one percent were so-called SIF (subchondral insufficiency fractures) detectable); it is assumed that this is the result of a relative overload in structurally or density reduced bone
- Other patients showed osteonecrosis (ON; “bone death”) or joint destruction with demonstrable bone loss (RPOA type 2).
Here, the authors discuss the following issue: they state that they do not know whether the observed damage was already proceeding at the time of injection or whether it is a consequence or complication of corticosteroid treatment. It is possible that the injections may have prevented pre-existing damage from healing?! Note: This is an observational study with a small number of cases.
There are other drugs that are designed to relieve and combat the discomfort and symptoms of coxarthrosis. However, the effectiveness of these agents is not assured. Therefore, no recommendation can be made for them.
Supplements (dietary supplements; vital substances)
Usually, drugs from the above groups are taken in combination with chondroprotectants/cartilage-protecting agents (e.g., glucosamine sulfate, chondroitin sulfate) to inhibit cartilage-degrading substances and provide relief or improvement of pain. In a multicenter intervention study with 606 gonarthrosis patients, it was demonstrated that the effect of glucosamine and chondroitin for the therapy of gonarthrosis showed identical effects as a drug treatment with the selective COX-2 inhibitor celecoxib.Both forms of therapy reduced the pain index of the gonarthrosis patients by approximately 50%. The reduction in joint swelling and joint effusions also decreased equally in both groups. For more information on chondroprotectants, see the following chapter. Note: Chondroprotectants should preferably be taken in combination with other bone-active vital substances, such as vitamins (C, D, E, K) and, if necessary, omega-3 fatty acids (docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)).
