The front-line pharmacotherapy for OA is designed to achieve analgesia, particularly with acetaminophen. Because of its safety and cost-effectiveness, it is the front-line treatment recommended in guidelines by the EULAR, the ACR, and others. The second-line treatment therapy used in treating OA is NSAIDs. Third-line treatment modalities exist for patients who failed to achieve pain control with acetaminophen or NSAIDs, or who had intolerances to or contraindications for their use. Third-line therapy includes opioids and atypical opioids (Arcangelo, et al., 2017). Cymbalta (Duloxetine), a drug used to treat depression, nerve pain, musculoskeletal pain, and other mood disorders was approved by the FDA in 2010 to treat OA aswell and can be used as a monotherapy or adjunct to NSAIDs or acetaminophen (Arcangelo, et al., 2017; Udell, 2017).
Acetaminophen works within the CNS by inhibiting central cyclooxygenase (COX) which causes a decrease in prostaglandin synthesis; does not have any anti-inflammatory actions but does have antipyretic (anti-fever) and analgesic (pain-relieving) effects. Patients usually experience pain relief in about one week following initiation of the drug. For maximum effectiveness scheduled dosing of acetaminophen, regardless of patient’s pain, should be initiated. The only outright contraindication for its use is hypersensitivity to itself. It should be used cautiously in who consume more than three alcoholic drinks/day and in patients with liver disease. Adverse reactions include rash and dizziness most commonly; however, liver failure and kidney toxicity has been associated with dosages that exceed the recommended daily allowance. Drug interactions may occur with the combination of acetaminophen and warfarin and/or isoniazide (Arcangelo, et al., 2017).NSAIDs all work by inhibiting COX which ultimately reduces inflammation and pain. There are two mechanisms of action used to facilitate this inhibition: 1) inhibition of the conversion of arachidonic acid to prostacyclin, prostaglandin, and thromboxanes; and 2) interference of proteinkinase activation. Dosing of NSAIDS is inconstant and are categorized as short-acting, long-acting, or intermediate-acting. Response to NSAIDs is also inconstant. Contraindications include pregnant patients, alcoholic patients, patients undergoing surgery, and patients allergic to aspirin (ASA). Also, some NSAIDS contain sulfa and are contraindicated in patients with sulfa allergies. Adverse reactions include weight gain, dizziness, nervousness, headache, tinnitus, visual changes, and easy bruising. NSAIDs should be used cautiously in patients with kidney or liver impairment as well as elderly patients. Drug interactions may occur when NSAIDS are used with warfarin, other anticoagulants, antihypertensives, lithium, etc. (Arcangelo, et al., 2017).
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- Arcangelo, Udell