NICE GUIDELINES 2022 to improve QoL & management of osteoarthritis

indomethacin and osteoarthritis
indomethacin and osteoarthritis

. OA is diagnosed clinically and usually does not need imaging to confirm diagnosis.

· Management is guided by symptoms and physical function.

· Core treatments are therapeutic exercise and weight management, alongside information and support.

· Manual therapy: Only consider for hip and knee OA and alongside therapeutic exercise.

· Devices: Consider walking aids for lower limb OA.

· Do not offer: Acupuncture or dry needling, Electrotherapy treatments, Insoles, braces, tape, splints or supports routinely.

· Pharmacological management: If needed, offer a topical NSAID for knee OA. Consider a topical NSAID for other OA affected joints. Consider an oral NSAID if topical medicines are ineffective or unsuitable and offer a gastroprotective treatment alongside.

· Do not offer: paracetamol or weak opioids routinely, unless used infrequently for short-term pain relief or all other treatments are ineffective/unsuitable; glucosamine, strong opioids, intra-articular hyaluronan injections.

· Consider intra-articular corticosteroid injections for short-term relief when other pharmacological treatments are ineffective/unsuitable or to support therapeutic exercise.

· Consider referring people with hip, knee or shoulder OA for joint replacement if: joint symptoms are substantially impacting their QoL and non-surgical management is ineffective/unsuitable. Do not exclude people from referral for joint replacement because of age, sex or gender, smoking, comorbidities, or overweight or obesity.

FINDINGS: Current practice in pharmacological treatment for OA varies in the types of treatments used and how people access treatment (such as buying medicines over the counter instead of accessing them through healthcare services). The NICE recommendations may cause changes in current practice towards using medicines for a shorter time, increasing use of topical NSAIDs, and reducing use of paracetamol and opioids.

NICE; 2022 Oct 19. (NICE Guideline, No. 226) page no. 32-34

PRESCRIPTION PRACTICES IN RHEUMATOID ARTHRITIS

A recent study conducted in 150 rheumatoid arthritis (RA) patients at AIIMS Rishikesh, Uttarakhand concludes that the most commonly prescribed disease modifying antirheumatic drug (DMARD) in RA was Methotrexate (MTX), followed by hydroxychloroquine (HCQ), leflunomide (Lef) and lastly adalimumab (Ada). The most commonly used regimen was MTX monotherapy followed by MTX + HCQ combination.

Along with DMARDs, adjuvant medications were also commonly prescribed to all patients. The adjuvant medications prescribed were Prednisolone, folic acid, naproxen, calcium, vitamin D and indomethacin.

On an average each patient received a total of six drugs at a time during the study duration.

There was a very high prevalence (61.4%) of complementary and alternative medicine (CAM) therapy in the patients here due to availability and accessibility despite poor response to this therapy.

J Family Med Prim Care 2021;10:745-51

TREAT & PREVENT RECURRENCE OF HETEROTOPIC OSSIFICATION POST EXCISION

The development of Heterotopic Ossification (HO) after hip procedures can be debilitating for some patients. Minimally invasive arthroscopic excision of HO and postoperative prophylaxis with combined indomethacin and radiation therapy effectively treats and prevents the recurrence of HO.

· This study approved by the New York University Langone Health IRB, included fourteen patients (5 female and 9 male) with an average age of 39 years (range 22-66) and average body mass index of 27.1 (19.1-37.5). Average follow-up time was 46 months.

· Patients were identified via retrospective review at a single urban academic medical center from August 2008 to November 2021. All patients were seen by a single sports medicine fellowship-trained orthopaedic surgeon and were treated with the same arthroscopic technique.

· HO prophylaxis regimen consisted of indomethacin 50 mg administered with meals for a 2-week course and radiation therapy with 700 cGy in one fraction on the first postoperative day.

· Outcomes assessed included recurrence of HO and conversion to total hip arthroplasty by latest follow-up. Other outcomes included Modified Harris Hip Scores and Non-Arthritic Hip Scores, which were collected preoperatively and at 1-year and 2-year follow-up.

· No patients had experienced HO recurrence by latest follow-up. Only 2 patients converted to total hip arthroplasty, one at 6 months and the other at 11 months post excision. Average outcome scores improved by 2-year follow-up.

Minimally invasive arthroscopic excision of HO and postoperative prophylaxis with combined indomethacin and radiation therapy effectively treats and prevents the recurrence of HO

Arthrosc Sports Med Rehabil. 2023;5(1):e165-e169

INDOMETHACIN IN TRIPLE THERAPY COMBINATION FOR PATIENTS OF RADIOULNAR SYNOSTOSIS.

In a post-traumatic radioulnar synostosis study of retrospective case series of 10 patients in Kuwait, radioulnar synostosis developed due to the most common cause -fractures.

A combination of adjuvant indomethacin, radiotherapy, and HO resection, followed by the insertion of an anconeus interposition flap was used in all 10 patients. Indomethacin dose and duration was 25 mg orally 3 times daily for a period of 2-4 weeks.

Results showed favorable outcomes with respect to range of motion, with improvements in flexion, extension, and rotation, as also the assessment of the subjective Mayo score.

Treating post-traumatic radioulnar synostosis with a combination of adjuvant indomethacin, radiotherapy, and tissue interposition with an anconeus flap after HO resection resulted in favorable functional outcomes and prevented recurrence in the study.

Indomethacin – a triple therapy component in rare HO cases

J Shoulder Elbow Surg. 2022;31(8):1595-1602

Review suggests nonselective NSAIDs may be more effective than selective NSAIDs, and some NSAIDs such as indomethacin might be preferable to other NSAIDs owing to its antinociceptive properties

Indomethacin superior in terms of pain score, time for rescue analgesia, compared to different NSAIDs

A meta-analysis and systematic review comparing the influence of control and individual NSAIDs on indices of analgesia, side effects, and quality of recovery in women undergoing caesarean section.

Interventions compared were: control vs celecoxib in two trials; control vs celecoxib + parecoxib in one trial; control vs diclofenac in 24 trials; control vs diclofenac vs indomethacin in one trial; control vs diclofenac vs ketoprofen in one trial; control vs ibuprofen vs ketorolac in one trial; control vs indomethacin in one trial; control vs ketorolac in six trials; control vs naproxen in one trial; control vs parecoxib in one trial; control vs tenoxicam in six trials; diclofenac vs ketoprofen in one trial; and ketorolac vs parecoxib in one trial.

In all, 47 trials were included. Cumulative intravenous morphine equivalent consumption at 24 h, the primary outcome, was examined in 1228 patients and 18 trials, and control was found to be inferior to diclofenac, indomethacin, ketorolac and tenoxicam.

Differences between various NSAIDs were found, with indomethacin clinically superior to celecoxib and celecoxib + parecoxib, diclofenac and ketorolac for the pain score at rest at 8 –12 h and the pain score on movement at 48 h, respectively, with a MCID of 10 on a pain scale of 0–100. In regard to the time for rescue analgesia, diclofenac, ibuprofen, indomethacin and ketorolac were clinically and statistically superior to celecoxib.

The superiority of indomethacin to other NSAIDs might be representative of its potential to act as a positive allosteric modulator at the type one cannabinoid receptor, modifying the endocannabinoid system and increasing its antinociceptive properties.

Review suggests nonselective NSAIDs may be more effective than selective NSAIDs, and some NSAIDs such as indomethacin might be preferable to other NSAIDs owing to its antinociceptive properties

Korean J Anesthesiol. 2023 Apr 17. doi: 10.4097/kja.23014.