Although spa therapy and low-level laser therapy may show some benefit, the true effectiveness cannot be determined, since the trials were small and of poor quality.17,18 No benefit was found in the one well-done RCT for ultrasound.19
Patient Education
Group patient education programs teach patients how to manage their disease. A 4-year longitudinal study using the Arthritis Self-Management Program (6 2-hour sessions), suggests that health education may decrease pain and visits to physicians.20,21 Estimated 4-year savings were $189 per patient.21 Telephone-based interventions have also been studied. A randomized trial of telephone contact for patients with OA found statistically significant differences in pain reduction according to the Arthritis Impact Measurement Scales at a very low cost.22,23 However, these differences may not be clinically significant as the groups differed by less than 1 point on a 10-point scale. Interestingly, educating patients during regularly scheduled appointments had no benefit and even resulted in worsening physical functioning.22 A systematic review of patient education interventions found a nonsignificant trend toward benefit using patient education compared with nonsteroidal anti-inflammatory drugs (NSAIDs).24 Despite the lack of convincing evidence from randomized trials, the possible benefits of educating our patients while using other therapies may outweigh the cost of the time involved, particularly if education can be done in a group setting.
Medication
Acetaminophen (4 g per day) has been shown in randomized trials to reduce pain in OA of the knee by approximately 30%.25,26 This improvement was seen at 4 weeks and at 2 years. Another study found the combination of codeine plus acetaminophen to be significantly better in reducing pain in patients with OA of the hip than acetaminophen alone, although one third of the patients receiving the combination discontinued therapy because of side effects.27 Narcotic analgesics alone have been shown in a randomized trial to be more effective in reducing pain than placebo but have not been adequately tested against acetaminophen or NSAIDs.28
NSAIDs also produce a 30% reduction in pain caused by OA.25,26 Two systematic reviews of OA concluded that there is no reliable evidence suggesting that any NSAID is more efficacious than the others in treating OA of the hip and knee.29,30 A separate meta-analysis found ibuprofen to have the lowest risk of side effects among the nonselective NSAIDs, a finding supported by the Committee on Safety in Medicine.31 For this reason, ibuprofen is recommended as the first-line nonselective NSAID.
Acetaminophen and NSAIDs have been found to be equally efficacious when compared in randomized controlled trials.25,26 According to a meta-analysis, the quality-of-life measures were similar between the 2 groups, despite a greater improvement in both pain at rest and pain on motion in the NSAID-treated patients.31 Interestingly, 2 recent surveys showed that patients with OA prefer NSAIDs to acetaminophen.27 However, based on the results of clinical trials, safety profiles, and cost issues acetaminophen should continue to be used as the first-line agent.27
The selective cyclooxygenase-2 (COX-2) inhibitors are effective in relieving the pain caused by OA.32-35 The COX-2 inhibitors have been shown to minimize fecal blood loss and produce fewer endoscopically proven gastrointestinal erosions/ulcerations than the nonselective inhibitors.36-39 This, however, is disease-oriented evidence and does not help us know about the more important clinical outcomes.
Using the STEPS approach (Safety, Tolerability, Efficacy, Price, Simplicity) to compare COX-2 inhibitors and nonselective NSAIDs is one way to help guide the choice of NSAIDs in the management of OA. A systematic review of a COX-2 inhibitor found the differences in adverse gastrointestinal events including perforations, symptomatic ulcers, and clinically significant bleeding episodes to be small when compared with the older NSAIDs (incidence = 1.3% vs 1.8%).36-39 Thus, 200 patients would have to receive a COX-2 inhibitor instead of a nonselective NSAID for 1 year to prevent 1 clinically significant bleeding episode (number needed to harm = 200). These safety differences seem small. However, the safety benefits of the COX-2 inhibitors increase when patients have multiple risk factors for adverse gastrointestinal events (age Ž65, history of peptic ulcer disease or gastrointestinal bleeding, use of oral glucocorticoids or anticoagulants, and comorbid medical conditions).27 Tolerability can be measured by looking at dropout rates. A meta-analysis found that the percentage of patients withdrawing from studies because of gastrointestinal adverse events was lower with the COX-2 inhibitor than with the nonselective NSAIDs (odds ratio = 0.59; 95% confidence interval, 0.52-0.67).37 Tolerability favors the COX-2 agents. Meta-analyses of trials comparing the efficacy of COX-2 inhibitors and nonselective NSAIDs in the treatment of OA show no differences between them.32-35 The average wholesale price of a month’s supply of a COX-2 inhibitor is approximately $73, and a month’s supply of a generic nonselective NSAID is $15. Nonselective NSAIDs are favored when looking at cost. While the nonselective NSAIDs require multiple dosing throughout the day, the COX-2 inhibitors can be given once daily, thus making the COX-2 inhibitors easier to use for patients. Overall, because of equal efficacy, minimal safety differences, and low cost, the older NSAIDs are recommended for low-risk patients, while the COX-2 inhibitors are recommended for high-risk patients because of increased safety and tolerability. (Of note, the COX-2 inhibitors have not been compared with acetaminophen, which is equally as efficacious as the nonselective NSAIDs and also has minimal side effects.)