What are the treatment options for highly resistant osteoarthritic pain?

Updated: Oct 12, 2020
  • Author: Carlos J Lozada, MD; Chief Editor: Herbert S Diamond, MD  more...
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In patients with highly resistant pain, consider the analgesic tramadol. However, in an observational study of more than 88,000 patients, an initial prescription of tramadol was associated with a significantly higher rate of mortality over 1 year of follow-up compared with commonly prescribed NSAIDs in patients aged 50 years and older. [76] The data from this study suggest an unfavorable safety profile of tramadol and require replication. Differences between the study groups (eg, cancer) that were not adjusted away using propensity score matching may account for part or even all of the difference in mortality rates. [77]

Similarly, a population-based study in British Columbia found that within 1 year of starting treatment, death rates were higher in patients taking tramadol than in those taking naproxen, diclofenac, or a selective cyclooxygenase (COX)-2 inhibitor. However, the all-cause mortality rate was lower with tramadol than with codeine. [78]

Options in patients at an elevated risk for GI toxicity from NSAIDs include the addition of a proton-pump inhibitor or misoprostol to the treatment regimen. Clinicians may also consider prescribing the COX-2 inhibitor celecoxib instead of a nonselective NSAID.

In June 2018, the US Food and Drug Administration (FDA) approved the combination of the calcium channel blocker amlodipine with celecoxib (Consensi), for patients for whom treatment with amlodipine for hypertension and celecoxib for osteoarthritis are appropriate. Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions, which is elevated in patients taking celecoxib. [79]

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