Therapeutic target
Relief of symptoms
Therapy recommendations
- For non-active osteoarthritis: analgesic/pain reliever paracetamol (best tolerated) Caution! No effect of paracetamol in patients with gonarthrosis (knee joint osteoarthritis). According to a meta-analysis, paracetamol is hardly effective in coxarthrosis and gonarthrosis.
- In activated osteoarthritis (abraded cartilage or bone material inflamed): non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac [not a long-term therapy!]
- If necessary, glucocorticoids; the effect of intra-articular injection (“into the joint cavity”) is controversially assessed (EULAR guideline: 1b; OARSI guideline: suitable; AAOS guideline: not suitable), but can be administered in case of otherwise uncontrollable inflammation.
Further notes
- Ibuprofen has been shown to increase blood pressure in osteoarthritis patients more than treatment with naproxen or celecoxib
- In terms of pain and function, in patients with gonarthrosis and coxarthrosis (knee and hip osteoarthritis), diclofenac – and, with slight reductions – etoricoxib work best.
- Caveat. According to a cohort study, 1-year mortality rates were significantly increased after short- to medium-term tramadol use as an analgesic compared with NSAIDs (naproxen, diclofenac, celecoxib, and etoricoxib) in patients with osteoarthritis. 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 an antiphlogistic (anti-inflammatory) and anti-edematous (decongestant) effect.
- The effect in intra-articular injection (“injection into the joint cavity”) is controversially assessed (EULAR guideline: 1b; OARSI guideline: suitable; AAOS guideline: not suitable), but can be administered in cases of inflammation that cannot be controlled otherwise.
- In a study involving a total of 100 patients with manifest gonarthrosis, half of each patient was treated by intra-articular injection with 40 mg/ml methylprednisolone dissolved in 4 ml lidocaine hydrochloride (10 mg/ml), and the other half received only a mixture of saline and lidocaine in a 4: 1 ratio. Pain was then assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS). There was no significant difference between the verum group and the placebo group.
General notes
- Intravenous administration (administration into the vein) does not provide any advantages over oral administration (“delivery by mouth”)
- 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).
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 gonarthrosis patients by approximately 50%. The decrease in joint swelling and joint effusion 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)).
