The NSAID and CVD Balancing Act

An Expert Interview With Daniel Solomon, MD

Linda Brookes; Daniel Solomon, MD


August 30, 2011

In This Article

A General Approach to Managing Chronic Pain

Medscape: In light of current knowledge, how would you advise physicians who need to prescribe pain medication for arthritis patients?

Dr. Solomon: Nonpharmacologic methods are the first line for several forms of arthritis. They include physical therapy, injections, heat, or cold. Assistive devices are worth considering. I would consider bracing for knee osteoarthritis, when there are deformities amenable to shifting the load. A cane can also be considered at first line, but it meets with some patient resistance. You can get into acupuncture or meditation, and many other nonpharmacologic therapies, but most patients are not interested in such treatments.

Low- to high-dose acetaminophen would be second line, and topical NSAIDs in combination with acetaminophen as third line. Oral NSAIDs at low to high doses with or without acetaminophen are next. Then, low potency opioids and adjunctive analgesics (tricyclic antidepressants, anticonvulsants, serotonin-norepinephrine reuptake inhibitors) as next line. These can be used in combination with acetaminophen and NSAIDs if necessary, but the total acetaminophen daily dosage must be considered. At some point the conversation has to be about joint replacement for someone with severe osteoarthritis.


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