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Practice question

A patient has osteoarthritis of the knees but cannot take NSAIDs. How can I provide pain relief?


Non-steroidal anti-inflammatory (NSAIDs) drugs are one of the mainstays of pain management for patients with osteoarthritis.

Swift A (2011) A patient has osteoarthritis of the knees but cannot take NSAIDs. How can I provide pain relief? Nursing Times; 107: 14, early online publication.

  • This article has been double-blind peer reviewed
  • Patients unable to take oral NSAIDs may benefit from using topical NSAIDs
  • Steroid injections into the joints can bring partial relief for up to three months
  • Patients need to maintain fitness to boost their quality of life

But there are risks associated with taking NSAIDS, including dyspepsia, renal and gastric complications, and an increased risk of thrombosis.

When patients are unable to take oral NSAIDs safely, other options need to be considered. It is worth exploring with a prescribing practitioner whether they may benefit from using topical NSAIDs, shown to be effective with fewer side-effects (Taylor et al, 2011). In clinical trials, capsaicin – a topical cream derived from the chilli pepper – was shown to be beneficial, although some find the initial burning sensation it produces to be off-putting (NICE, 2008).

Paracetamol is as effective as NSAIDs for some, but taking the maximum dose over the longer term is associated with gastrointestinal effects. Some guidelines suggest the next step should be tramadol or other opioid medications, but this view is not endorsed by NICE guidance (Zhang et al, 2010); NICE found the research evidence to support the use of opioids in osteoarthritic pain was not convincing (NICE, 2008). Opioids can be combined with paracetamol to reduce the required dosage and therefore side-effects. However, long-term opioid use can lead to tolerance and dependence and has side-effects including nausea and constipation.

Steroid injections into the joints can bring partial relief for up to three months, but there is a lack of rigorous placebo- controlled trials and efficacy may be limited (Avouac et al, 2007). Risks include infection and instability of blood glucose for people with diabetes. Glucosamine on its own or combined with chondroitin are probably not helpful for osteoarthritis pain, but some find it useful in knee pain and no harm has been demonstrated from its use.

Non-pharmacological strategies should be used along with analgesia. People with osteoarthritis need to maintain fitness to help them remain independent and to boost their quality of life. Exercise helps to alleviate pain in many people and fitness has a positive influence on postoperative recovery for those who have joint replacement (Topp et al, 2009).

Physiotherapists can give advice and support although many patients only need help to keep active and fit. Concordance depends partly on pain management and, in addition to drug treatment, acupuncture and transcutaneous electrical nerve stimulation are useful. Heat or cold applied to joints can provide short-term relief. There are many complementary therapies but, as yet, there is no evidence to support their use and they can be a financial burden on the patient.

Obesity is a major risk factor in the development of osteoarthritis and is associated with a greater need for joint replacement surgery. Obese patients also have a greater risk of joint infection after surgery and are advised to lose weight beforehand. Weight reduction is itself a beneficial pain management strategy (Zhang et al, 2010).

Amelia Swift is a lecturer, University of Birmingham, School of Health and Population Sciences, College of Medical and Dental Sciences



Readers' comments (2)

  • I have a relative who requires tramadol for pain. In his opinion, he does not give a monkeys about becoming addicted, as long as the pain is gone and he can live his life. As he also points out, the pain is permanent and never going to go away so any pain relief he would have to take would be permanent, so does it matter if it is addictive, if he would have to take it anyway?

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  • Tramadol is thought to have less of an addictive potential than other opioids. Addiction is a serious concern however as it implies a loss of control over the use of the drug accompanied by negative side effects even when the drug is ineffective in the control of pain. If pain relief is effective and there are no associated harms then there is no reason why your relative should not continue with it. There are many medicines however that do cause more harms when used in the long term and all patients need to discuss their use with their GP, rheumatologist of pain consultant.

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