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Rheumatic pain management
In daily practice
Pain Grid
I II III IV V VI
Acute (Incident Focused)
Monophasic Pain
Acute (Diagnostically
Focused) Recurrent
Pain
Chronic Malignancy
Based Pain
Chronic Progressive
Non-Malignancy Based
Pain
Chronic
NonProgressive
NonMalignancy Based
Pain
Chronic Benign Pain
Examples Examples Examples Examples Examples Examples
Post Operative, Major
Trauma, Acute Phase of
Burns, Fractures, Pre- and
Post-Procedural Scenarios,
Acute Back Pain Syndromes
Sickle Cell Crisis, Acute
Flare of Inflammatory
Bowel Disease, Acute
Flares of Inflammatory
Arthropathies, Hemophilic
Arthropathy, Renal
Calculi, Forms of Back
Pain, Dysmenorrhea,
Migraine
Self Explanatory based
on local spread,
metastatic invasion,
pressure or obstruction
A.I.D.S. Progression,
Sickle Cell Patients,
Hemophilia Patients,
Some Connective Tissue
Diseases, Inflammatory
Bowel Disease with Short
Gut and ExtraGut
Autoimmune
Manifestations
Musculoskeletal Pain
Syndromes
(Osteoporosis,
spondylolisthesis), TMJ,
Neuropathic Pain
Syndromes (Postherpetic
neuralgia, painful
polyneuropathy, RSD),
Forms of Back Pain
Pain Associated with a
Marked Discrepancy in
Pathologic Findings
compared against Strong
and Typical Axis I, Axis II
and Premorbid
Psychosocial Features
Opioid Advisability Opioid Advisability Opioid Advisability Opioid Advisability Opioid Advisability Opioid Advisability
OK Ok (with cautions) Advised OK
Relative
Contraindication
Opioid Avoidance
Courtesy of Craig Pratt, MD (with some
changes)
Rheumatic pain
3
Symptoms
■ Joint pain
■ Joint swelling
■ Morning stiffness
■ Fatigue
■ Weight loss
■ Flu-like symptoms
4
The goal of pain management
is
not necessarily pain relief – it is improving a
patient’s quality of life.
Symptomatic Treatments
■ Education/support
■ Rest/relaxation
■ Joint protection
■ Physiotherapy
■ Analgesics
■ Anti-inflammatory drugs
■ Steroids
■ Joint injections
■ Pain Management Clinics
6
Symptomatic Treatments
■ Education/support
■ Rest/relaxation
■ Joint protection
■ Physiotherapy
■ Analgesics
■ Anti-inflammatory drugs
■ Steroids
■ Joint injections
■ Pain Management Clinics
7
What are the benefits and risks from
NSAIDs?
How do I reduce the GI risks?
How do I reduce the CV risks?
Are there specific safety concerns with
NSAIDs?
*Note by NSAIDs we mean traditional NSAIDs (e.g. diclofenac,
naproxen, ibuprofen); etodolac, meloxicam, or coxibs (e.g. celecoxib,
etoricoxib)
Key questions regarding NSAIDs*
Common Rheumatic problems:
Osteoarthritis and Rheumatoid Arthritis
Rheumatic pain management
Prevalence of Arthritis in US Adults*
■ 49.9 million (22.2%) with self-reported, physician-diagnosed arthritis†1
■ 21.1 million (9.4%) with arthritis and arthritis-attributable activity limitation1
■ Affects more women than men in every age group2
0
20
40
60
80
100
18–24 25–34 35–44 45–54 55–64 65–74 75–84 85+
Women Men
Age Group, years
* Data sources: 2007-2009 data from the National Health Interview Survey (NHIS). † Includes multiple forms of arthritis.
HCP=health care professional.
1. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(39):1261-1265.
2. Graphic adapted from CDC. NHIS Arthritis Surveillance: Arthritis Prevalence in Women and Men.
www.cdc.gov/arthritis/data_statistics/national_nhis.htm. Accessed January 12, 2011.
3. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(16):421-426.
4. Hootman JM, Helmick CG. Arthritis Rheum. 2006;54(1):226-229.
■ Arthritis and rheumatism → leading causes of disability in US3
■ By 2030, a projected 67 million in US will have HCP-diagnosed arthritis4
USAdults(%)
WithArthritis
Factors Implicated in the Development of OA
Cartilage breakdown
ObesityObesity
Anatomic
abnormalities
Anatomic
abnormalities
Microfractures
and bony
remodeling
Microfractures
and bony
remodeling
Loss of joint
stability
Loss of joint
stability
TraumaTrauma
AgingAging
Genetic and
metabolic
diseases
Genetic and
metabolic
diseases
InflammationInflammation
Immune
system
activity
Immune
system
activity
Compromised cartilage
Biophysical changes
• Collagen network fracture
• Proteoglycan unraveling
Biochemical changes
• Inhibitors reduced
• Proteolytic enzymes increased
Abnormal stresses Abnormal cartilage
Mandelbaum B et al. Orthopedics. 2005;28(2 suppl):s207-s214.
Adapted with permission from 2002 Medtronic Sofamor Danek, Basic Bone Biology.
EULAR Diagnostic Criteria for Knee OA (2010)
■ Based on review of studies from 1950-2008 and expert consensus
■ Focuses on clinical diagnosis: presence of three symptoms and
three signs correctly diagnoses 99% of cases
SymptomsSymptoms
1 Persistent knee pain √
2 Limited morning stiffness √
3 Reduced function √
SignsSigns
4 Joint crepitus √
5 Restricted movement √
6 Bony enlargement √
EULAR=European League Against Rheumatism.
Zhang W et al. Ann Rheum Dis. 2010;69(3):483-489.
ACR Diagnostic Criteria for Knee OA (1986)
■ Clarified and standardized definition of osteoarthritis
 Joint symptoms and signs associated with defective integrity of
articular cartilage and changes in underlying joints at bone margin
■ Focuses on clinical examination of knee pain plus:
■ Sensitivity, 95%; specificity, 69%
Presence of 3 of the followingPresence of 3 of the following
1 Age >50 years √
2 Morning stiffness <30 minutes √
3 Joint crepitus on active motion √
4 Bony tenderness √
5 Bony enlargement √
6 No palpable warmth of synovium √
ACR=American College of Rheumatology.
Altman RD et al. Arthritis Rheum. 1986;29(8):1039-1049.
Goals of OA Management:
OARSI Recommendations
Reduce
joint pain and
stiffness
Reduce
physical
disability
Improve
HRQoL
Educate
patients
Limit
progression of
joint damage
Knee and Hip OA:
Goals of
Treatment
HRQoL=health-related quality of life; OARSI=Osteoarthritis Research Society International.
Zhang W et al. Osteoarthritis Cartilage. 2008;16(2):137-162.
Maintain and
improve joint
mobility
Integrated Approach to Treating Patients With OA
NonpharmacologicNonpharmacologic PharmacologicPharmacologic
■ Patient education
■ Phone contact (promote self-care)
■ Referral to physical therapist
■ Aerobic, strengthening, and/or water-
based exercise
■ Weight reduction
■ Walking aids, knee braces
■ Proper footwear, insoles
■ Thermal modalities
■ TENS
■ Acupuncture
■ APAP
■ Oral NSAIDs
■ Topical NSAIDs and capsaicin
■ Corticosteroid injections
■ Hyaluronate injections
■ Glucosamine, chondroitin sulphate,
and/or diacerein
■ Weak opioids and narcotic analgesics
for refractory pain*
SurgicalSurgical
■ Total joint replacement
■ Unicompartmental knee replacement
■ Osteotomy and other joint preserving
surgical procedures
■ Lavage/debridement in knee OA†
■ Joint fusion after failure of joint
replacement
* Pain resistant to ordinary treatment. † Controversial.
TENS=transcutaneous electrical nerve stimulation.
Zhang W et al. Osteoarthritis Cartilage. 2008;16(2):137-162.
US Prevalence and Burden of
Rheumatoid Arthritis (RA)
■ May affect between 1.3 and 1.5 million
adults1,2
Incidence lowest in individuals aged ≤34 years
Incidence increases progressively with age
Occurs more commonly in women than in men
■ Societal costs3
* Costs in 2005 US dollars.
1. Myasoedova E et al. Arthritis Rheum. 2010;62(6):1576-1582.
2. Helmick CG et al. Arthritis Rheum. 2008;58(1):15-25.
3. Birnbaum H et al. Curr Med Res Opin. 2010;26(1):77-90.
Hand RA
Photos from Towheed TE, Anastassiades TP. Can Fam Phys. 1994;40:1303-1309. Used with permission.
2010 ACR / EULAR Diagnostic Criteria for RA
CriterionCriterion ScoreScore
A Joint Involvement*
1 large joint 0
2-10 large joints 1
1-3 small joints (± large-joint involvement) 2
4-10 small joints (± large-joint involvement) 3
>10 joints (at least 1 small joint) 5
B Serology†
Negative RF and negative ACPA 0
Low-positive RF or low-positive ACPA 2
High-positive RF or high-positive ACPA 3
C
Acute-Phase
Reactants‡
Normal CRP and normal VHS 0
Abnormal ESR or CRP 1
D
Duration of
Symptoms§
Less than 6 weeks 0
6 or more weeks 1
Total score ≥6/10Total score ≥6/10
needed to classifyneeded to classify
definite RAdefinite RA
Total score ≥6/10Total score ≥6/10
needed to classifyneeded to classify
definite RAdefinite RA
* Any swollen or tender joint on examination. Excluded are distal interphalangeal joints, first carpometacarpal joints, and first
metatarsophalangeal joints. Large joints = shoulders, elbows, hips, knees, and ankles. Small joints = metacarpophalangeal joints, proximal
interphalangeal joints, 2nd through 5th metatarsophalangeal joints, thumb interphalangeal joints, and wrists. The >10 category can include large
and small joints, and other joints not listed elsewhere (eg, temporomandibular, acromioclavicular, or sternoclavicular). † Negative: IU values
≤ULN for lab and assay. Low-positive: IU > ULN but ≤3x ULN. High-positive: IU >3x ULN. When only RF-positive or RF-negative is known,
positive scored as low-positive. ‡ Normal/abnormal determined by local lab standards. § Patient self-report of duration of signs/symptoms of
synovitis in joints clinically involved at time of assessment, regardless of treatment status.
ACPA=anti-citrullinated protein/peptide antibodies; CRP=C-reactive protein; VHS =erythrocyte sedimentation rate; RF=rheumatoid factor.
Aletaha D et al. Arthritis Rheum. 2010;62(9):2569-2581.
Goals of RA Management
Reduce pain
Prevent or
control joint
damage
Prevent
functional
decline
Maximize
patient
quality of life
Early and Sustained
Suppression of Disease Activity
ACR Subcommittee on Rheumatoid Arthritis Guidelines. Arthritis Rheum. 2002;46(2):328-346.
Treatment Options for Patients With RA1-3
NSAIDsNSAIDs  Symptomatic treatment to reduce joint swelling and pain
DMARDsDMARDs
(biologic and(biologic and
nonbiologic)nonbiologic)
 Reduce/prevent joint damage, preserve joint integrity and function
 Methotrexate, leflunomide, hydroxychloroquine, minocycline,
sulfasalazine
 Etanercept, infliximab, adalimumab (TNF inhibitors)
 Rituximab (anti-CD20)
 Abatacept (cytotoxic T-lymphocyte antigen 4 immunoglobulin)
 Tocilizumab (anti-interleukin 6 receptor)
GlucocorticoidsGlucocorticoids
 Short-term use during flare-ups (oral or intramuscular)
 Local treatment for individual active joints (intra-articular)
SurgerySurgery
 Carpal tunnel release, synovectomy, resection of metatarsal heads,
total joint arthroplasty, joint fusion
SupportiveSupportive
StrategiesStrategies
 Patient education, cognitive-behavioral interventions
 Rehabilitation interventions
DMARDs=disease-modifying antirheumatic drugs; TNF=tumor necrosis factor.
1. ACR Subcommittee on Rheumatoid Arthritis Guidelines. Arthritis Rheum. 2002;46(2):328-346.
2. Saag KG et al. Arthritis Rheum. 2008;59(6):762-784.
3. Smolen JS et al. Lancet. 2007;370(9602):1861-1874.
Distinguishing OA From RA1
CharacteristicCharacteristic OAOA RARA
Prevalence in US adults 27 million2
1.3–1.5 million3,4
Pathophysiologic process Degenerative Autoimmune
Commonly affected joints
Hips, knees, spine,
fingers
Hands, feet
Typically symmetrical
involvement
No Yes
Morning stiffness Transient Persistent
Joint swelling Hard tissue Soft tissue
Hand involvement Distal joints Proximal joints
Extraarticular involvement No Yes
Elevated autoimmune markers No Yes
1. Goldman L, Ausiello D. Cecil Textbook of Medicine. 23rd ed. Philadelphia, PA: Saunders Elsevier; 2007.
2. Lawrence RC et al. Arthritis Rheum. 2008;58(1):26-35.
3. Helmick CG et al. Arthritis Rheum. 2008;58(1):15-25.
4. Myasoedova E et al. Arthritis Rheum. 2010;62(6):1576-1582.
1991: A New Paradigm for COX Biology
GlucocorticoidsGlucocorticoids
(block mRNA(block mRNA
expression)expression)
Arachidonic AcidArachidonic Acid
COX-1COX-1
(Constitutive)(Constitutive)
COX-2COX-2
(Cytokine(Cytokine
Inducible)Inducible)
StomachStomach
IntestineIntestine
KidneyKidney
PlateletPlatelet
Inflammatory Site:Inflammatory Site:
• MacrophagesMacrophages
• SynoviocytesSynoviocytes
• Endothelial cellsEndothelial cells
NSAIDsNSAIDsx x
McKenna F et al. Scand J Rheumatol 2001;30:11–18.
VAS=visual analogue scale.
LessPain
Patient’s Assessment of Pain (VAS): Mean change at
week 6
MeanChange(mm)
*p=0.001 vs. placebo
placebo
(n=200)
celecoxib
100 mg BID
(n=199)
diclofenac
50 mg TID
(n=199)
Coxibvs. diclofenac:
6-week Knee OA Trial
McKenna et al. 2001: Patient’s Assessment of Pain
McKenna F et al. Scand J Rheumatol. 2001;30:11-18.
American Pain Society (APS) Pain Measure:
Worst Pain in the Past 24 Hours
MeanChangeinScore
p=0.05, active treatment vs.
placebo (days 1-7).
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
Baseline Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
placebo (n=200)
celecoxib 100 mg BID (n=199)
diclofenac 50 mg TID (n=199)
LessPain
Coxibsvs. diclofenac:
6-week Knee OA Trial
McKenna et al. 2001: American Pain Society – Pain
Measure
Gastrointestinal Safety
Risk of upper GI ulcer bleeding
Lanas A, et al. Gut 2006;55:1731–38
Guidelines for Prevention of
NSAID-Related Ulcer Complications
(ACG Practice Guidelines 2009)
za FL et al. Am J Gastroenterol 2009;104:728-738
Cardiovascular Safety
Primary Endpoint: Cumulative Incidence of
Thrombotic CV Events
30
Etoricoxib (320 events)
Diclofenac (323 events)
Months
No. of patients at risk*
Etoricoxib
Diclofenac
16,819
16,483
13,359 10,733 8277 6427 4024 805
81538326213790110,14212,800
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0
6 12 18 24 30 36 420
Cumulativeincidence(%)with95%CI
Etoricoxib vs diclofenac
HR = 0.95
95% CI = (0.81-1.11)
*Per protocol population.
Boxed Warning for All Prescription NSAIDs
Cardiovascular Risk
NSAIDs may cause an increased risk of serious cardiovascular thrombotic events,
myocardial infarction, and stroke, which can be fatal. This risk may increase with
duration of use. Patients with cardiovascular disease or risk factors for
cardiovascular disease may be at greater risk.
[Product] is contraindicated for the treatment of perioperative pain in the setting
of coronary artery bypass graft (CABG) surgery.
Gastrointestinal Risk
NSAIDs, including Coxibs, cause an increased risk of serious gastrointestinal
adverse events including bleeding, ulceration, and perforation of the stomach or
intestines, which can be fatal. These events can occur at any time during use and
without warning symptoms. Elderly patients are at greater risk for serious
gastrointestinal (GI) events.
Cardiovascular Risk
NSAIDs may cause an increased risk of serious cardiovascular thrombotic events,
myocardial infarction, and stroke, which can be fatal. This risk may increase with
duration of use. Patients with cardiovascular disease or risk factors for
cardiovascular disease may be at greater risk.
[Product] is contraindicated for the treatment of perioperative pain in the setting
of coronary artery bypass graft (CABG) surgery.
Gastrointestinal Risk
NSAIDs, including Coxibs, cause an increased risk of serious gastrointestinal
adverse events including bleeding, ulceration, and perforation of the stomach or
intestines, which can be fatal. These events can occur at any time during use and
without warning symptoms. Elderly patients are at greater risk for serious
gastrointestinal (GI) events.
So what does this mean for us?
■ BOTH NSAIDs and coxibs are associated to
varying degrees with increased CV risk
■ We must consider co-morbidities and concurrent
medications that may sway risk
■ Older patients are at increased risk of CV, GI and
renal side effects – weigh up risk/benefit
■ Both NSAIDs and coxibs are viable and effective
options to treat pain and have manageable side
effect profiles
33
Arthritic patients with hypertension
NSAIDs: Renal risks
MHRA DSU. May 2009
Renal risk
SUMMARY
■ Arthritis Pain is major health problem in our population
■ NSAIDs is scientifically proven to alleviate arthritis pain
(OA, RA)
■ In patients with risk of GI tract afflection combine
diclofenac with PPI
■ Diclofenac has a well-tolerated safety profille
35
■ NICE advises against use of any NSAID in those
taking low-dose aspirin
■ Avoid tNSAIDs and coxibs in those with history of
heart failure
■ Avoid tNSAID or coxib in those with GFR <30, use with
caution when GFR 30<60
36
Practical Advice
■ Prescribe lowest effective dose for the shortest period of
time
■ In chronic pain consider as required dosing and review
regularly
■ Advise patient regarding potential side effects and do what
you can to minimise risks
■ Monitor BP, renal function and liver function in those on
long term
Have an enjoyable learning
Thank you

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Rheumatic pain management

  • 2. Pain Grid I II III IV V VI Acute (Incident Focused) Monophasic Pain Acute (Diagnostically Focused) Recurrent Pain Chronic Malignancy Based Pain Chronic Progressive Non-Malignancy Based Pain Chronic NonProgressive NonMalignancy Based Pain Chronic Benign Pain Examples Examples Examples Examples Examples Examples Post Operative, Major Trauma, Acute Phase of Burns, Fractures, Pre- and Post-Procedural Scenarios, Acute Back Pain Syndromes Sickle Cell Crisis, Acute Flare of Inflammatory Bowel Disease, Acute Flares of Inflammatory Arthropathies, Hemophilic Arthropathy, Renal Calculi, Forms of Back Pain, Dysmenorrhea, Migraine Self Explanatory based on local spread, metastatic invasion, pressure or obstruction A.I.D.S. Progression, Sickle Cell Patients, Hemophilia Patients, Some Connective Tissue Diseases, Inflammatory Bowel Disease with Short Gut and ExtraGut Autoimmune Manifestations Musculoskeletal Pain Syndromes (Osteoporosis, spondylolisthesis), TMJ, Neuropathic Pain Syndromes (Postherpetic neuralgia, painful polyneuropathy, RSD), Forms of Back Pain Pain Associated with a Marked Discrepancy in Pathologic Findings compared against Strong and Typical Axis I, Axis II and Premorbid Psychosocial Features Opioid Advisability Opioid Advisability Opioid Advisability Opioid Advisability Opioid Advisability Opioid Advisability OK Ok (with cautions) Advised OK Relative Contraindication Opioid Avoidance Courtesy of Craig Pratt, MD (with some changes)
  • 4. Symptoms ■ Joint pain ■ Joint swelling ■ Morning stiffness ■ Fatigue ■ Weight loss ■ Flu-like symptoms 4
  • 5. The goal of pain management is not necessarily pain relief – it is improving a patient’s quality of life.
  • 6. Symptomatic Treatments ■ Education/support ■ Rest/relaxation ■ Joint protection ■ Physiotherapy ■ Analgesics ■ Anti-inflammatory drugs ■ Steroids ■ Joint injections ■ Pain Management Clinics 6
  • 7. Symptomatic Treatments ■ Education/support ■ Rest/relaxation ■ Joint protection ■ Physiotherapy ■ Analgesics ■ Anti-inflammatory drugs ■ Steroids ■ Joint injections ■ Pain Management Clinics 7
  • 8. What are the benefits and risks from NSAIDs? How do I reduce the GI risks? How do I reduce the CV risks? Are there specific safety concerns with NSAIDs? *Note by NSAIDs we mean traditional NSAIDs (e.g. diclofenac, naproxen, ibuprofen); etodolac, meloxicam, or coxibs (e.g. celecoxib, etoricoxib) Key questions regarding NSAIDs*
  • 9. Common Rheumatic problems: Osteoarthritis and Rheumatoid Arthritis
  • 11. Prevalence of Arthritis in US Adults* ■ 49.9 million (22.2%) with self-reported, physician-diagnosed arthritis†1 ■ 21.1 million (9.4%) with arthritis and arthritis-attributable activity limitation1 ■ Affects more women than men in every age group2 0 20 40 60 80 100 18–24 25–34 35–44 45–54 55–64 65–74 75–84 85+ Women Men Age Group, years * Data sources: 2007-2009 data from the National Health Interview Survey (NHIS). † Includes multiple forms of arthritis. HCP=health care professional. 1. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(39):1261-1265. 2. Graphic adapted from CDC. NHIS Arthritis Surveillance: Arthritis Prevalence in Women and Men. www.cdc.gov/arthritis/data_statistics/national_nhis.htm. Accessed January 12, 2011. 3. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(16):421-426. 4. Hootman JM, Helmick CG. Arthritis Rheum. 2006;54(1):226-229. ■ Arthritis and rheumatism → leading causes of disability in US3 ■ By 2030, a projected 67 million in US will have HCP-diagnosed arthritis4 USAdults(%) WithArthritis
  • 12. Factors Implicated in the Development of OA Cartilage breakdown ObesityObesity Anatomic abnormalities Anatomic abnormalities Microfractures and bony remodeling Microfractures and bony remodeling Loss of joint stability Loss of joint stability TraumaTrauma AgingAging Genetic and metabolic diseases Genetic and metabolic diseases InflammationInflammation Immune system activity Immune system activity Compromised cartilage Biophysical changes • Collagen network fracture • Proteoglycan unraveling Biochemical changes • Inhibitors reduced • Proteolytic enzymes increased Abnormal stresses Abnormal cartilage Mandelbaum B et al. Orthopedics. 2005;28(2 suppl):s207-s214. Adapted with permission from 2002 Medtronic Sofamor Danek, Basic Bone Biology.
  • 13. EULAR Diagnostic Criteria for Knee OA (2010) ■ Based on review of studies from 1950-2008 and expert consensus ■ Focuses on clinical diagnosis: presence of three symptoms and three signs correctly diagnoses 99% of cases SymptomsSymptoms 1 Persistent knee pain √ 2 Limited morning stiffness √ 3 Reduced function √ SignsSigns 4 Joint crepitus √ 5 Restricted movement √ 6 Bony enlargement √ EULAR=European League Against Rheumatism. Zhang W et al. Ann Rheum Dis. 2010;69(3):483-489.
  • 14. ACR Diagnostic Criteria for Knee OA (1986) ■ Clarified and standardized definition of osteoarthritis  Joint symptoms and signs associated with defective integrity of articular cartilage and changes in underlying joints at bone margin ■ Focuses on clinical examination of knee pain plus: ■ Sensitivity, 95%; specificity, 69% Presence of 3 of the followingPresence of 3 of the following 1 Age >50 years √ 2 Morning stiffness <30 minutes √ 3 Joint crepitus on active motion √ 4 Bony tenderness √ 5 Bony enlargement √ 6 No palpable warmth of synovium √ ACR=American College of Rheumatology. Altman RD et al. Arthritis Rheum. 1986;29(8):1039-1049.
  • 15. Goals of OA Management: OARSI Recommendations Reduce joint pain and stiffness Reduce physical disability Improve HRQoL Educate patients Limit progression of joint damage Knee and Hip OA: Goals of Treatment HRQoL=health-related quality of life; OARSI=Osteoarthritis Research Society International. Zhang W et al. Osteoarthritis Cartilage. 2008;16(2):137-162. Maintain and improve joint mobility
  • 16. Integrated Approach to Treating Patients With OA NonpharmacologicNonpharmacologic PharmacologicPharmacologic ■ Patient education ■ Phone contact (promote self-care) ■ Referral to physical therapist ■ Aerobic, strengthening, and/or water- based exercise ■ Weight reduction ■ Walking aids, knee braces ■ Proper footwear, insoles ■ Thermal modalities ■ TENS ■ Acupuncture ■ APAP ■ Oral NSAIDs ■ Topical NSAIDs and capsaicin ■ Corticosteroid injections ■ Hyaluronate injections ■ Glucosamine, chondroitin sulphate, and/or diacerein ■ Weak opioids and narcotic analgesics for refractory pain* SurgicalSurgical ■ Total joint replacement ■ Unicompartmental knee replacement ■ Osteotomy and other joint preserving surgical procedures ■ Lavage/debridement in knee OA† ■ Joint fusion after failure of joint replacement * Pain resistant to ordinary treatment. † Controversial. TENS=transcutaneous electrical nerve stimulation. Zhang W et al. Osteoarthritis Cartilage. 2008;16(2):137-162.
  • 17. US Prevalence and Burden of Rheumatoid Arthritis (RA) ■ May affect between 1.3 and 1.5 million adults1,2 Incidence lowest in individuals aged ≤34 years Incidence increases progressively with age Occurs more commonly in women than in men ■ Societal costs3 * Costs in 2005 US dollars. 1. Myasoedova E et al. Arthritis Rheum. 2010;62(6):1576-1582. 2. Helmick CG et al. Arthritis Rheum. 2008;58(1):15-25. 3. Birnbaum H et al. Curr Med Res Opin. 2010;26(1):77-90.
  • 18. Hand RA Photos from Towheed TE, Anastassiades TP. Can Fam Phys. 1994;40:1303-1309. Used with permission.
  • 19. 2010 ACR / EULAR Diagnostic Criteria for RA CriterionCriterion ScoreScore A Joint Involvement* 1 large joint 0 2-10 large joints 1 1-3 small joints (± large-joint involvement) 2 4-10 small joints (± large-joint involvement) 3 >10 joints (at least 1 small joint) 5 B Serology† Negative RF and negative ACPA 0 Low-positive RF or low-positive ACPA 2 High-positive RF or high-positive ACPA 3 C Acute-Phase Reactants‡ Normal CRP and normal VHS 0 Abnormal ESR or CRP 1 D Duration of Symptoms§ Less than 6 weeks 0 6 or more weeks 1 Total score ≥6/10Total score ≥6/10 needed to classifyneeded to classify definite RAdefinite RA Total score ≥6/10Total score ≥6/10 needed to classifyneeded to classify definite RAdefinite RA * Any swollen or tender joint on examination. Excluded are distal interphalangeal joints, first carpometacarpal joints, and first metatarsophalangeal joints. Large joints = shoulders, elbows, hips, knees, and ankles. Small joints = metacarpophalangeal joints, proximal interphalangeal joints, 2nd through 5th metatarsophalangeal joints, thumb interphalangeal joints, and wrists. The >10 category can include large and small joints, and other joints not listed elsewhere (eg, temporomandibular, acromioclavicular, or sternoclavicular). † Negative: IU values ≤ULN for lab and assay. Low-positive: IU > ULN but ≤3x ULN. High-positive: IU >3x ULN. When only RF-positive or RF-negative is known, positive scored as low-positive. ‡ Normal/abnormal determined by local lab standards. § Patient self-report of duration of signs/symptoms of synovitis in joints clinically involved at time of assessment, regardless of treatment status. ACPA=anti-citrullinated protein/peptide antibodies; CRP=C-reactive protein; VHS =erythrocyte sedimentation rate; RF=rheumatoid factor. Aletaha D et al. Arthritis Rheum. 2010;62(9):2569-2581.
  • 20. Goals of RA Management Reduce pain Prevent or control joint damage Prevent functional decline Maximize patient quality of life Early and Sustained Suppression of Disease Activity ACR Subcommittee on Rheumatoid Arthritis Guidelines. Arthritis Rheum. 2002;46(2):328-346.
  • 21. Treatment Options for Patients With RA1-3 NSAIDsNSAIDs  Symptomatic treatment to reduce joint swelling and pain DMARDsDMARDs (biologic and(biologic and nonbiologic)nonbiologic)  Reduce/prevent joint damage, preserve joint integrity and function  Methotrexate, leflunomide, hydroxychloroquine, minocycline, sulfasalazine  Etanercept, infliximab, adalimumab (TNF inhibitors)  Rituximab (anti-CD20)  Abatacept (cytotoxic T-lymphocyte antigen 4 immunoglobulin)  Tocilizumab (anti-interleukin 6 receptor) GlucocorticoidsGlucocorticoids  Short-term use during flare-ups (oral or intramuscular)  Local treatment for individual active joints (intra-articular) SurgerySurgery  Carpal tunnel release, synovectomy, resection of metatarsal heads, total joint arthroplasty, joint fusion SupportiveSupportive StrategiesStrategies  Patient education, cognitive-behavioral interventions  Rehabilitation interventions DMARDs=disease-modifying antirheumatic drugs; TNF=tumor necrosis factor. 1. ACR Subcommittee on Rheumatoid Arthritis Guidelines. Arthritis Rheum. 2002;46(2):328-346. 2. Saag KG et al. Arthritis Rheum. 2008;59(6):762-784. 3. Smolen JS et al. Lancet. 2007;370(9602):1861-1874.
  • 22. Distinguishing OA From RA1 CharacteristicCharacteristic OAOA RARA Prevalence in US adults 27 million2 1.3–1.5 million3,4 Pathophysiologic process Degenerative Autoimmune Commonly affected joints Hips, knees, spine, fingers Hands, feet Typically symmetrical involvement No Yes Morning stiffness Transient Persistent Joint swelling Hard tissue Soft tissue Hand involvement Distal joints Proximal joints Extraarticular involvement No Yes Elevated autoimmune markers No Yes 1. Goldman L, Ausiello D. Cecil Textbook of Medicine. 23rd ed. Philadelphia, PA: Saunders Elsevier; 2007. 2. Lawrence RC et al. Arthritis Rheum. 2008;58(1):26-35. 3. Helmick CG et al. Arthritis Rheum. 2008;58(1):15-25. 4. Myasoedova E et al. Arthritis Rheum. 2010;62(6):1576-1582.
  • 23. 1991: A New Paradigm for COX Biology GlucocorticoidsGlucocorticoids (block mRNA(block mRNA expression)expression) Arachidonic AcidArachidonic Acid COX-1COX-1 (Constitutive)(Constitutive) COX-2COX-2 (Cytokine(Cytokine Inducible)Inducible) StomachStomach IntestineIntestine KidneyKidney PlateletPlatelet Inflammatory Site:Inflammatory Site: • MacrophagesMacrophages • SynoviocytesSynoviocytes • Endothelial cellsEndothelial cells NSAIDsNSAIDsx x
  • 24. McKenna F et al. Scand J Rheumatol 2001;30:11–18. VAS=visual analogue scale. LessPain Patient’s Assessment of Pain (VAS): Mean change at week 6 MeanChange(mm) *p=0.001 vs. placebo placebo (n=200) celecoxib 100 mg BID (n=199) diclofenac 50 mg TID (n=199) Coxibvs. diclofenac: 6-week Knee OA Trial McKenna et al. 2001: Patient’s Assessment of Pain
  • 25. McKenna F et al. Scand J Rheumatol. 2001;30:11-18. American Pain Society (APS) Pain Measure: Worst Pain in the Past 24 Hours MeanChangeinScore p=0.05, active treatment vs. placebo (days 1-7). -4.0 -3.5 -3.0 -2.5 -2.0 -1.5 -1.0 -0.5 0.0 Baseline Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 placebo (n=200) celecoxib 100 mg BID (n=199) diclofenac 50 mg TID (n=199) LessPain Coxibsvs. diclofenac: 6-week Knee OA Trial McKenna et al. 2001: American Pain Society – Pain Measure
  • 27. Risk of upper GI ulcer bleeding Lanas A, et al. Gut 2006;55:1731–38
  • 28. Guidelines for Prevention of NSAID-Related Ulcer Complications (ACG Practice Guidelines 2009) za FL et al. Am J Gastroenterol 2009;104:728-738
  • 30. Primary Endpoint: Cumulative Incidence of Thrombotic CV Events 30 Etoricoxib (320 events) Diclofenac (323 events) Months No. of patients at risk* Etoricoxib Diclofenac 16,819 16,483 13,359 10,733 8277 6427 4024 805 81538326213790110,14212,800 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0 6 12 18 24 30 36 420 Cumulativeincidence(%)with95%CI Etoricoxib vs diclofenac HR = 0.95 95% CI = (0.81-1.11) *Per protocol population.
  • 31. Boxed Warning for All Prescription NSAIDs Cardiovascular Risk NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. This risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk. [Product] is contraindicated for the treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery. Gastrointestinal Risk NSAIDs, including Coxibs, cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients are at greater risk for serious gastrointestinal (GI) events. Cardiovascular Risk NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. This risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk. [Product] is contraindicated for the treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery. Gastrointestinal Risk NSAIDs, including Coxibs, cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients are at greater risk for serious gastrointestinal (GI) events.
  • 32. So what does this mean for us? ■ BOTH NSAIDs and coxibs are associated to varying degrees with increased CV risk ■ We must consider co-morbidities and concurrent medications that may sway risk ■ Older patients are at increased risk of CV, GI and renal side effects – weigh up risk/benefit ■ Both NSAIDs and coxibs are viable and effective options to treat pain and have manageable side effect profiles
  • 34. NSAIDs: Renal risks MHRA DSU. May 2009 Renal risk
  • 35. SUMMARY ■ Arthritis Pain is major health problem in our population ■ NSAIDs is scientifically proven to alleviate arthritis pain (OA, RA) ■ In patients with risk of GI tract afflection combine diclofenac with PPI ■ Diclofenac has a well-tolerated safety profille 35
  • 36. ■ NICE advises against use of any NSAID in those taking low-dose aspirin ■ Avoid tNSAIDs and coxibs in those with history of heart failure ■ Avoid tNSAID or coxib in those with GFR <30, use with caution when GFR 30<60 36
  • 37. Practical Advice ■ Prescribe lowest effective dose for the shortest period of time ■ In chronic pain consider as required dosing and review regularly ■ Advise patient regarding potential side effects and do what you can to minimise risks ■ Monitor BP, renal function and liver function in those on long term
  • 38. Have an enjoyable learning Thank you

Notas del editor

  1. These slides should be used in conjunction with the accompanying notes
  2. Data from the 2007-2009 National Health Interview Survey reveal high rates of self-reported, doctor-diagnosed arthritis and limitations due to arthritis. 1 In addition, in every adult age group, women are more likely to be affected by arthritis than men. 2 Arthritis and rheumatism are the leading causes of disability in the United States, 3 and it is estimated that by 2030, 67 million Americans will have health care practitioner-diagnosed arthritis. 4 References: Centers for Disease Control and Prevention. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation — United States, 2007–2009. MMWR Morb Mortal Wkly Rep . 2010;59(39):1261-1265. Centers for Disease Control and Prevention. NHIS Arthritis Surveillance: Arthritis Prevalence in Women and Men . www.cdc.gov/arthritis/data_statistics/national_nhis.htm. Accessed January 12, 2011. Centers for Disease Control and Prevention. Prevalence and most common causes of disability among adults—United States, 2005. MMWR Morb Mortal Wkly Rep . 2009;58(16):421-426. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum . 2006;54(1):226-229.
  3. This slide provides an overview of the factors that can contribute to the development of OA. These factors can be divided into two groups: those placing abnormal stress on the cartilage, such as obesity and anatomic abnormalities, and those contributing to abnormalities of the cartilage, such as aging and genetic diseases. All of these factors can contribute to compromised cartilage and ultimately result in cartilage breakdown. Reference: Mandelbaum B, Waddell D. Etiology and pathophysiology of osteoarthritis. Orthopedics . 2005;28(2 suppl):s207-s214.
  4. In 2010, the European League Against Rheumatism (EULAR) provided six criteria—three symptoms and three signs—that could be used to correctly diagnose OA of the knee in 99% of cases, when all six criteria are present. The three symptoms are: Persistent knee pain Limited morning stiffness Reduced function The three signs are: Joint crepitus Restricted movement Bony enlargement Reference: Zhang W, Doherty M, Peat G, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis . 2010;69(3):483-489.
  5. In 1986 the American Rheumatism Association—now the American College of Rheumatology (ACR)—developed criteria to diagnose OA on the basis of knee pain and three of the following six criteria: Age older than 50 years Less than 30 minutes of morning stiffness Joint crepitus Bony tenderness Bony enlargement Absence of palpable warmth The sensitivity and specificity of these criteria were 95% and 69%, respectively. Reference: Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee. Arthritis Rheum . 1986;29(8):1039-1049.
  6. Consensus guidelines from the Osteoarthritis Research Society International (OARSI) indicate six key goals for the treatment of knee and hip OA. Four of these goals relate to the patient’s physical state: Reduce joint pain and stiffness Maintain and improve joint mobility Reduce physical disability Limit progression of joint damage The other two key goals are to educate the patient about OA and its management, and to improve patient’s health-related quality of life. Reference: Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage . 2008;16(2):137-62.
  7. The Osteoarthritis Research Society International (OARSI) consensus guidelines describe an integrated approach to treating patients with OA, including nonpharmacologic, pharmacologic, and surgical interventions. Nonpharmacologic aspects of treatment include such interventions as patient education, exercise, weight reduction, and the nondrug therapies transcutaneous electrical nerve stimulation (TENS) and acupuncture. Listed among the pharmacologic treatments are acetaminophen, selective and nonselective NSAIDs, steroid injections, glucosamine and chondroitin, and for some patients, weak opioids and narcotic analgesics. Surgical interventions listed in the guidelines include total joint replacement, joint fusion in cases of replacement failure, unicompartmental knee replacement, osteotomy, and lavage and debridement in knee OA, although this last approach is controversial. Reference: Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage . 2008;16(2):137-62.
  8. Although less common than OA, rheumatoid arthritis (RA) has a major impact on the lives of patients with this chronic disorder. Prevalence estimates vary, but RA may affect as many as 1.5 million adults in the United States. 1,2 The incidence of RA is lowest among individuals aged 34 years and younger; thereafter the incidence increases progressively with age. 2 The economic impact of RA is sizable. A recently published study using administrative claims databases covering privately insured and Medicare and Medicaid beneficiaries in the United States to compute the excess payer and beneficiary-paid costs per patient with RA compared with matched controls revealed 3 : $8.4 billion in annual direct costs (2005 US dollars), which includes medical visits and prescription medications. $10.9 billion in annual indirect costs (2005 US dollars), which includes expenses such as healthcare costs for family members, work-loss costs, formal and informal caregiving, home adaptations, and other costs related to consequences of RA On a per-patient basis, these cost represents approximately $14,900 per patient with RA. References: Myasoedova E, Crowson CS, Kremers HM, Therneau TM, Gabriel SE. Is the incidence of rheumatoid arthritis rising? Results from Olmsted County, Minnesota, 1955-2007. Arthritis Rheum . 2010;62(6):1576-1582. Helmick CG, Felson DT, Lawrence RC, et al; National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum . 2008;58(1):15-25. Birnbaum H, Pike C, Kaufman R, Maynchenko M, Kidolezi Y, Cifaldi M. Societal cost of rheumatoid arthritis patients in the US. Curr Med Res Opin . 2010;26(1):77-90.
  9. These photographs of the hands of patients with RA can be contrasted with those of patients with OA. In the upper left photograph, the hands of a patient with active, recent-onset RA show bilateral synovitis of the metacarpal phalangeal joints with subluxation, an early Z-shaped deformity of the right thumb, a developing boutonniere deformity of the right 3rd digit, and bilateral ulnar drift. In the lower right photograph, the hands show bilateral ulnar drift, subluxation of the metacarpal phalangeal joints, bilateral intrinsic muscle atrophy, fixed hyperextension deformities of the right 2nd-4th proximal interphalangeal joints with developing swan-neck deformities of the 4th and 5th digits, and fixed flexion deformities of the left 2nd-5th proximal interphalangeal joints (second to fifth), with fully developed boutonniere deformities of the left 2nd-5th digits. Reference: Towheed TE, Anastassiades TP. Rheumatoid hand: practical approach to assessment and management. Can Fam Phys . 1994;40:1303-1309.
  10. In 2010, experts from the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) worked jointly to revise the diagnostic criteria for RA. The result is a score-based classification system for patients 1) with at least one joint showing definite clinical synovitis (swelling), and 2) whose synovitis is not better explained by another disease. Four categories are used to assess (A) joint involvement, (B) serology, (C) acute-phase reactants, and (D) duration of symptoms. The highest possible score is 10, and a score of six or higher is needed to classify the condition as definite RA. Reference: Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid Arthritis Classification Criteria: an American College of Rheumatology/European League Against Rheumatism Collaborative Initiative. Arthritis Rheum . 2010;62(9):2569-2581.
  11. Guidelines from the American College of Rheumatology focus on early and sustained suppression of disease activity in RA, and present four key goals for management: Reduce pain Prevent or control damage to the affected joints Prevent functional decline Maximize quality of life for the patient Reference: ACR Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum . 2002;46(2):328-46.
  12. Treatment options for patients with RA can be divided into five categories: NSAIDs, disease-modifying agents, glucocorticoids, surgical approaches, and supportive strategies. 1-3 Symptomatic treatment with NSAIDs can reduce joint swelling and pain. disease-modifying antirheumatic drugs (DMARDs) can reduce or prevent joint damage and preserve joint integrity and function. Glucocorticoids can be used in the short term to treat flare-ups. Surgical approaches include carpal tunnel release, synovectomy, resection of metatarsal heads, total joint arthroplasty, and joint fusion. Lastly, supportive strategies include patient education, cognitive-behavioral therapy, and rehabilitation. References: ACR Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum . 2002;46(2):328-46. Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum . 2008;59(6):762-784. Smolen JS, Aletaha D, Koeller M, Weisman MH, Emery P. New therapies for treatment of rheumatoid arthritis. Lancet . 2007;370(9602):1861-1874.
  13. A number of features can be helpful in distinguishing OA from RA: OA is more than 20 times more prevalent than RA. 1-3 The pathophysiologic processes of the two arthritides are distinct: OA is primarily a degenerative process, whereas RA is an autoimmune, primarily inflammatory disease. 4 OA usually begins as a monoarticular condition, particularly of the large joints. Multiple joints are frequently affected simultaneously with RA, and the condition has a predilection for the smaller joints of the hands and feet. In RA, joint involvement is often symmetrical. 4 Clinical features of the diseases can also be distinguished by the duration of morning stiffness and the nature of joint swelling. When hand joints are involved, OA typically affects distal joints, whereas RA typically affects the proximal joints. 4 Extra-articular involvement—for example, of the skin, lungs, eyes, and blood vessels—in RA reflects the underlying autoimmune nature of the disease, and high levels of autoimmune markers are used for diagnosis. 4 References: Lawrence RC, Felson DT, Helmick CG, et al; National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum . 2008;58(1):26-35. Helmick CG, Felson DT, Lawrence RC, et al; National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum . 2008;58(1):15-25. Myasoedova E, Crowson CS, Kremers HM, Therneau TM, Gabriel SE. Is the incidence of rheumatoid arthritis rising? Arthritis Rheum . 2010;62(6):1576-1582. Goldman L, Ausiello D. Cecil Textbook of Medicine . 23rd ed. Philadelphia, PA: Saunders Elsevier; 2007.
  14. 4 14
  15. 09/25/09 Key point: Celecoxib relieves OA pain of the knee as effectively as diclofenac. Background: All efficacy outcomes were significantly superior with celecoxib compared with placebo at both week 2 and week 6. In the primary efficacy analysis of patient’s assessment of pain by VAS, there was no statistically significant difference between celecoxib and diclofenac. Reference: McKenna F et al. Celecoxib versus diclofenac in the management of osteoarthritis of the knee: a placebo-controlled, randomised, double-blind comparison. Scand J Rheumatol 2001;30:11-18.
  16. 09/25/09 Key point: Celecoxib decreased APS pain measure of worst pain in the past 24 hours as effectively as diclofenac. Background: Celecoxib reduced the amount of acute pain experienced by patients with knee OA compared with placebo within the first 24 hours of therapy. The American Pain Society (APS) pain measures were significantly improved with celecoxib compared with placebo on day 1, and this response was maintained throughout the 7-day evaluation period ( p &lt;0.01). By day 7, 7% of patients taking placebo, 17% of those treated with celecoxib, and 15% of those treated with diclofenac reported no pain ( p &lt;0.01, active treatment vs. placebo). Pain response was similar between celecoxib and diclofenac groups. Reference: McKenna F et al. Celecoxib versus diclofenac in the management of osteoarthritis of the knee: a placebo-controlled, randomised, double-blind comparison. Scand J Rheumatol 2001;30:11-18.
  17. Patients with risk factors for cardiovascular disease (i.e., prior history of a cardiovascular event, diabetes, hypertension, hyperlipidemia, and obesity) oI en receive prophylactic aspirin. - ey may bene5 t from the substitution of a less cardiotoxic NSAID instead of a COX-2 inhibitor. Naproxen may be the agent of choice as it may have some cardioprotective properties (76,98,108,109,112) . In addition, these patients should receive a PPI or misoprostol because the combination of naproxen and low-dose aspirin markedly increases the risk of GI bleeding. Patients at very high GI risk who also have increased CV risk should not be treated with NSAIDs or coxibs and another form of treatment should be considered. Reference: Lanza FL et al. Am J Gastroenterol 2009;104:728-738 09/25/09
  18. In April 2005, the FDA issued request letters to manufacturers of all NSAIDs, asking that they make labeling changes to their products. 1 These letters included recommended labeling for both prescription and over-the-counter NSAIDs and a medication guide for the entire class of prescription products. All manufacturers of marketed prescription NSAIDs, including Celebrex (celecoxib), were asked to revise the labeling (package insert) for their products to include a boxed warning (shown), which highlights the potential for an increased risk of cardiovascular (CV) events. 2-4 Manufacturers of over-the-counter NSAIDs were also asked to revise their labeling to provide more specific information about the potential CV risks of their individual products. References: FDA. COX-2 selective (includes Bextra, Celebrex, and Vioxx) and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). April 7, 2005. www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ ucm103420.htm. Accessed January 12, 2011. Celebrex [package insert]. New York, NY: Pfizer Inc.; June 2009. EC-Naprosyn/Naprosyn/Anaprox/Anaprox DS [package insert]. Nutley, NJ: Roche Pharmaceuticals; July 2008. Voltaren-XR [package insert]. East Hanover, NJ: Novartis; March 2009.
  19. These slides should be used in conjunction with the accompanying notes