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Indian Journal for the Practising Doctor

A Critical Analysis of the Pharmacological Treatment of Osteoarthritis in a Tertiary Care Hospital

Author(s): Durgaprasad S, Rao V B, Rath M

Vol. 5, No. 5 (2008-11 - 2008-12)

Durgaprasad S, Rao V B, Rath M

ISSN: 0973-516X

Dr S. Durgaprasad, MD, (Assistant Professor), Department of Pharmacology, KMC International Centre, Manipal 576104.
Dr Vijaya Bhasker Rao and Dr Meera Rath, postgraduate scholars, Department of Pharmacology, Kasturba Medical College, Manipal
Dr S. Durgaprasad
, Assistant Professor, Department of Pharmacology, KMC International Centre, Manipal 576104.
[e-mail: drago301 (at)]


Background: Osteoarthritis (OA) or degenerative joint disease is the most common form of arthritis. Pharmacological treatment of OA includes NSAIDs and nutritional supplements. Among the NSAIDs paracetamol is widely recommended as the first line drug. This stance is supported by published guidelines.
Aim: To find out the extent of use of paracetamol in mild to moderate cases of osteoarthritis
Design: Retrospective
Materials and Methods: Case files of mild to moderate osteoarthritis seen in the year 2005 & 2006 in the Kasturba Medical College Hospital (Manipal) were obtained from MRD.
Results: Out of the total 598 studied cases, 4% patients received paracetamol alone, 37.5% patients received paracetamol and ibuprofen combination, 20.5% patients were prescribed glucosamine with NSAIDs and 38% patients had been prescribed COX-2 inhibitors.
Discussion: Among the NSAIDs paracetamol is widely recommended as the first line drug for OA. Its safety and efficacy as compared to other NSAIDs has been established time and again. In our study we found that only 46% of patients received paracetamol. The reasons for paracetamol not being used in a majority may be multiple, including better patient compliance and stronger marketing of COX-2 inhibitors,
Conclusions: Paracetamol is not being used in a majority of patients, despite the strong evidence for its safety and efficacy in OA.
Key words: Osteoarthritis, NSAID, Paracetamol, COX-2 inhibitors, Glucosamine


Osteoarthritis (OA), resulting from degeneration of the joint cartilage, is the most common form of arthritis. Degenerative changes are the predominant factor contributing to disability1. These may affect any joint in the body, including those in fingers, hips, knees, lower back and feet. In joints with osteoarthritis, inflammation may be present; however, it is usually mild and involves only the periarticular tissues. Nearly everyone has osteoarthritis-related radiographic changes in the knees or other joints by the age of 75, although most individuals have no symptoms2. Osteoarthritis is characterised by focal loss of cartilage and hypertrophic bone spurs3. The causes of cartilage loss are multiple. In most people, cartilage breakdown is due both to mechanical (“wear and tear”) factors and biochemical effects. Any event that changes the environment of the chondrocyte has the potential to cause osteoarthritis4. Although usually occurring as a primary disorder; osteoarthritis can occur secondary to other processes. In the past OA was regarded as a simple wear and tear phenomenon wherein the weight bearing joints simple wore out or degenerated with advancing age. However, the disease is now viewed as an active process in which specific biochemical change occurs in the joint fluid, the cartilage and the subchondral bone. Earlier some of these changes were thought to be reparative responses to normal joint insults leading to a hope that these changes can be manipulated and reversed towards improved outcomes. But it is now established that once these changes are initiated they are self-sustaining and the degeneration progresses slowly. The main symptom that patients complain of is pain; especially with use of the joint5 .Other symptoms include joint stiffness, limitation of movement, variable degrees of local inflammation and loss of function. Men and women are equally affected, but symptoms occur earlier and appear to be more severe in women6.

Therapy for OA includes both medication and other treatments that help to relieve pain and improve joint function. Pharmacological treatment includes paracetamol/NSAIDs and nutritional supplements like glucosamine and chorndroitin sulphate. Paracetamol is widely recommended as the first–line drug in the management of osteoarthritis. This is based on its efficacy and safety as compared with other NSAIDs, including cyclooxygenase 2(COX-2) inhibitors. This position is supported by published guidelines, including those of the American College of Rheumatology(ACR)7 and the European League of Associations of Rheumatology (EULAR)8. In these guidelines, NSAIDs are recommended for use in moderate to severe pain (ACR guidelines) or where the pain is unresponsive to paracetamol (EULAR guidelines). The Australian Therapeutic Guideline series and the National Prescribing Service publications similarly recommend paracetamol as the first-line treatment in osteoarthritis9. Based on cost, efficacy and safety, paracetamol as needed up to 4 g/day should be the first-line pharmacologic therapy for osteoarthritis10.

The aim of the present study was to find out the extent of prescription of paracetamol alone or in combination in mild to moderate OA and to compare its use with that of the COX-2 inhibitors

Materials and Methods: The study was conducted in the Kasturba Medical College Hospital, Manipal. Approval of the institutional review board and the permission to access the case files of OA patients was obtained. The case files of mild to moderate OA of the knee were obtained from medical records department for analysis. Cases of recent knee replacement surgery or those with OA of more than three years were excluded. A total numbers of 598 mild to moderate cases were scrutinized. The prescriptions were recorded on a case record form per the following parameters: i) Paracetamol vs other NSAIDs ii) COX-2 inhibitors vs NSAIDs iii) Analgesics vs nutritional supplements iv) Monotherapy vs combination therapy. The recorded data was analyzed using Microsoft Excel programme

Results and Discussion: The data revealed that 24 (4%) of the patients received paracetamol alone and 224 (37.5%) patients received paracetamol and ibuprofen combination, while 122 (20.5%) patients were prescribed glucosamine with NSAIDs and 228 (38%) patients COX-2 inhibitors.

The study throws light on some interesting prescription patterns. Paracetamol is being prescribed in quite a number of patients as per the guidelines (Chart No. 1), however, a majority is not getting it (Chart No.2). There is a trend among those who treat OA to favour COX-2 inhibitors (Chart No. 3). The reasons for this inclination may be multiple. Paracetamol is an effective agent for pain relief due to OA. Although safer, paracetamol is less effective than NSAIDs. For safety reasons, paracetamol should be the first line treatment, with NSAIDs reserved for those who do not respond to paracetamol. At the same time there is emerging evidence that COX-2 inhibitors (like Rofecoxib, 25 mg/d), have efficacy advantages over acetaminophen, 4000 mg/d, for symptomatic knee OA11. Once-a day doses of celecoxib (200 mg) and rofecoxib (25 mg) offer comparable efficacy and are an effective alternative to conventional NSAIDs in the management of OA12. But the available data raises a cautionary flag about the risk of cardiovascular side-effects with COX-2 inhibitors13. Further prospective trial evaluation may characterise and determine the magnitude of the risk. Cox -2 inhibitors are substantially more expensive and definitely not safer than paracetamol. In such a scenario it makes economic sense to prescribe paracetamol more often. The authors strongly feel that paracetamol should have been prescribed to a larger number of OA patients. The limitations of this study are that the results only represent the prescription pattern of OA in one tertiary care hospital and may not necessarily be generalized. The number of cases could also be a limiting factor. Yet it does indicate an alarming trend among physicians to ignore international therapeutic guidelines and fall into the hands of aggressive promoters of their products.

Conclusions: Although paracetamol is the first drug of choice for OA, it is not being used in a majority of patients when indicated as per the guidelines. There is an unwelcome trend to prescribe COX-2 inhibitors which pose an unnecessary economic burden on the patient.

Drugs used in OA patients

Number of patients receiving paracetamol vs other drugs

Number of patients receiving NSAIDS vs Other drugs


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