10: Musculoskeletal & joint diseases

• Before prescribing an NSAID establish that the pain is not controlled by regular paracetamol 1g QDS, especially if chronic use is indicated and particularly in the elderly.
• In osteoarthritis and soft tissue pain, NSAIDs should only be prescribed if simple analgesia (see section 4.7.1) and non-pharmacological treatment have failed.
• All NSAIDs (including selective inhibitors of cyclo-oxygenase-2 [COX-2]) are contraindicated in patients with active gastro-intestinal ulceration or bleeding.
• Non-selective NSAIDs are contraindicated in patients with a history of recurrent gastro-intestinal ulceration or haemorrhage (two or more distinct episodes), and in patients with a history of gastro-intestinal bleeding or perforation related to previous NSAID therapy.
• NSAIDs should be used with caution in renal, cardiac and hepatic disease
• For advice on NSAID allergy and NSAID-sensitive asthma see NICE CG183 (Drug allergy: diagnosis and management)

Cardiovascular events
Cyclo-oxygenase-2 selective (COX-2) inhibitors are associated with an increased risk of thrombotic events (e.g. myocardial infarction and stroke) and should not be used in preference to non-selective NSAIDs except when specifically indicated (i.e. for patients at a particularly high risk of developing gastroduodenal ulceration or bleeding) and after assessing their cardiovascular risk. COX-2 inhibitors are contraindicated in patients with existing cardiovascular disease.

Standard NSAIDs may also be associated with a increased risk of thrombotic events, particularly when used at high doses and for long-term treatment. Diclofenac appears to be associated with a similar excess risk to that of the COX-2 inhibitors, whereas naproxen and low dose ibuprofen (up to 1.2g/day) are associated with a lower thrombotic risk and should be used in preference to other NSAIDs in patients with cardiovascular disease.

Gastro-intestinal toxicity

All NSAIDs are associated with serious gastro-intestinal toxicity; the risk is higher in the elderly.

Low risk: Ibuprofen
Intermediate risk: Diclofenac, naproxen, ketoprofen, indometacin, piroxicam
High risk: Azapropazone

COX-2 inhibitors are associated with a lower risk of serious upper G.I. side effects than standard NSAIDs however this advantage may be lost in patients who require concomitant low-dose aspirin.

The lowest effective dose of NSAID should be prescribed for the shortest period to control symptoms and the need for long-term treatment should be reviewed periodically.

Concomitant gastroprotection should be prescribed where appropriate.

GHNHSFT Local Guideline: Oral PPI Guideline

• Treatment with corticosteroids in rheumatic diseases should be reserved for specific indications e.g. when other anti-inflammatory drugs are unsuccessful.
• Corticosteroids can induce osteoporosis; therefore, bone protection should be considered for patients on treatment for longer than 3 months. National Osteoporosis Guideline Group: Guideline for the diagnosis and management of osteoporosis (May 2013)
• Enteric Coated (EC) prednisolone tablets are not recommended (UKMi advice)

Disease-modifying antirheumatic drugs (DMARDs) should only be initiated by specialists.

None