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Pharmakotherapie bei Arthroseschmerzen

Pharmacological treatment of osteoarthritis-related pain

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Zusammenfassung

Ein hoher Anteil insbesondere der älteren Bevölkerung leidet unter Gelenkschmerzen aufgrund einer Arthrose, die zu einer wesentlichen Beeinträchtigung des Alltags und der Lebensqualität sowie zur Behandlung führen. Unzählige medikamentöse Gelenkschmerztherapien werden in der klinischen Praxis angeboten. Der vorliegende Artikel präsentiert die aktuelle Studienlage zur pharmakologischen Therapie bei Arthroseschmerzen unter Berücksichtigung von Leitlinien und umfasst topische, orale und intraartikulär injizierte Arzneimittel. Bei geringfügigen Gelenkschmerzen bietet sich die topische Anwendung von nichtsteroidalen Antirheumatika (NSAR) an. Die lokale Applikation von Capsaicin beschränkt sich auf Patienten, bei denen andere Therapiemöglichkeiten nicht angeschlagen haben oder kontraindiziert sind. Bei stärkeren Schmerzen kann die zeitlich begrenzte orale Einnahme von NSAR empfohlen werden, sofern das unerwünschte Arzneimittelwirkungsprofil des Präparats und patientenbezogene gastrointestinale, kardiovaskuläre und renale Komorbiditäten streng berücksichtigt werden. Bei Patienten mit Polyarthrose und Komorbiditäten, die einen oralen NSAR-Einsatz risikoreich machen, kann die Einnahme von Duloxetin erwogen werden. Für die orale Anwendung von Metamizol, Chondroprotektiva und Nahrungsergänzungsmitteln liegt keine klare Evidenz in der Therapie von Arthroseschmerzen vor. Der standardmäßige Einsatz von Opioiden wird nicht empfohlen. Bei starken Gelenkschmerzen können intraartikuläre Glukokortikoidinjektionen zu kurzfristiger Schmerzlinderung führen. Für intraartikuläre Injektionen von Hyaluronsäure oder autologem konditioniertem Plasma gibt es keine eindeutige Evidenz. Die Effizienz der Effekte einer Pharmakotherapie bei Arthroseschmerzen ist oft widersprüchlich und mögliche schwerwiegende unerwünschte Arzneimittelwirkungen müssen beachtet werden. Ein kritischer Umgang mit diesen therapeutischen Optionen unter Einbezug patientenbezogener Komorbiditäten und nichtpharmakologischer Therapie ist deshalb unerlässlich.

Abstract

Joint pain due to osteoarthritis (OA) is often severe and disabling and affects a large proportion of the aging population impairing daily living and quality of life. Numerous pharmacological treatment approaches are available. Including major OA guidelines this review presents the current evidence of pharmacological therapies in OA-related pain and covers topical, oral and intraarticular treatment approaches. In patients with mild OA topical nonsteroidal antiinflammatory drugs (NSAIDs) can be recommended. Topical capsaicin can be used when other treatments are ineffective or contraindicated. In patients with moderate to severe OA oral NSAIDs are suggested at the lowest effective dose for the shortest possible duration to control symptoms. Importantly, drug-related side effects and gastrointestinal, cardiovascular and renal comorbidities need to be taken into account. In patients with multiple-joint OA and high risk of NSAID-induced adverse events duloxetine can be considered. The evidence of metamizole, symptomatic slow-acting drugs in osteoarthritis and other nutritional supplements in the treatment of OA pain is uncertain and the use of opioids is not routinely recommended. In patients suffering from severe OA-related pain intraarticular injections with glucocorticoids can be suggested to achieve short-term pain relief. Evidence for interventional approaches using hyaluronic acid or platelet-rich plasma is uncertain. Yet, the efficacy of pharmacological therapies in OA-related pain is often inconsistent and severe adverse events might occur. Thus, critical use of the different treatment options considering patient-related comorbidities and nonpharmacological therapies is of major importance.

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Nees, T.A., Schiltenwolf, M. Pharmakotherapie bei Arthroseschmerzen. Schmerz 33, 30–48 (2019). https://doi.org/10.1007/s00482-018-0286-6

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