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Friday, May 19, 2017

The Acceleration of Articular Cartilage Degeneration in Osteoarthritis by Nonsteroidal Anti-inflammatory Drugs

The preponderance of scientific evidence shows that NSAIDs damage articular cartilage. Various scientific papers and consensus groups have stated that there is no convincing data to show that the widely used NSAIDs and recommended selective COX-2 inhibitors have favorable effects on cartilage.129-131 Even the main consensus paper from the International Cartilage Repair Society and Osteoarthritis Research Society International stated that NSAID use has to be limited to the short term. Specifically the recommendation was as follows: In patients with symptomatic hip or knee osteoarthritis, non-steroidal anti-inflammatory drugs (NSAIDs) should be used at the lowest effective dose but their long-term use should be avoided if possible.132 They also noted that NSAIDs should not be first-line therapy for joint OA. Other groups have raised similar sentiments. The committees of the International League Against Rheumatism and the World Health Organization came up with guidelines for the testing of new drugs in osteoarthritis. The consensus from these meetings resulted in recommendations by The European Group for the Respect of Ethics and Excellence in Science (GREES) for governmental registration and approval of new drugs used in the treatment of OA and have added the requirement that the drug not have a deleterious effect on the diseased and non-diseased contra lateral joint; i.e., no deleterious effect on osteoarthritic or normal cartilage.133 If this latter recommendation were followed, the vast majority, if not all NSAIDs, would be immediately taken off the market and no new ones would get approved.

While it is admirable for the various consensus and rheumatology organizations to educate doctors and the lay public about the necessity to limit NSAID use in OA, this author (RH) feels the warnings are not enough. Within the last year, for instance, the FDA has again implemented new rules requiring stronger and more extensive label warnings (in addition to the heart disease risks) regarding the risk of liver damage and stomach bleeding for people taking common over-the-counter pain relievers. As for NSAIDs, the new regulations require front labels to instruct users to see new warnings that say, "This product contains a nonsteroidal anti-inflammatory drug (NSAID), which may cause severe stomach bleeding. The chance is higher if you are age 60 or older, have had stomach ulcers or bleeding problems, take a blood thinning or steroid drug, take other drugs containing prescription or nonprescription NSAIDs, have three or more alcoholic drinks every day using this product, take more or for a longer time than directed."134

The lay public for whom NSAIDs are prescribed and recommended by both health care professionals and drug manufacturers should be aware that long-term NSAID use is detrimental to articular cartilage. Specifically, be informed that NSAIDs will likely worsen the OA disease for which it is prescribed. Physicians, allied health care professionals, and drug manufacturers should be required to inform the lay public that NSAID use can accelerate OA articular cartilage degeneration. A strict warning label on these medications should read as follows:

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