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Topical Therapies for Osteoarthritis

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Abstract

This review discusses the pharmacology, analgesic efficacy, safety and tolerability of topical NSAIDs, salicylates and capsaicin for the management of osteoarthritis (OA) pain. Topical therapies present a valuable therapeutic option for OA pain management, with substantial evidence supporting the efficacy and safety of topical NSAIDs, but less robust support for capsaicin and salicylates. We define topical therapies as those intended to act locally, in contrast to transdermal therapies intended to act systemically.

Oral therapies for patients with mild to moderate OA pain include paracetamol (acetaminophen) and NSAIDs. Paracetamol has only weak efficacy at therapeutic doses and is hepatotoxic at doses >3.25g/day. NSAIDs have demonstrated efficacy in patients with OA, but are associated with dose-, duration- and age-dependent risks of gastrointestinal, cardiovascular, renal, haematological and hepatic adverse events (AEs), as well as clinically meaningful drug interactions. To minimize AE risks, treatment guidelines for OA suggest minimizing NSAID exposure by prescribing the lowest effective dose for the shortest duration of time. Systemic NSAID exposure may also be limited by prescribing topical NSAIDs, particularly in patients with OA pain limited to a few superficial joints.

Topical NSAIDs have been available in Europe for decades and were introduced to provide localized analgesia with minimal systemic NSAID exposure. Guidelines of the American Academy of Orthopaedic Surgeons, European League Against Rheumatism (EULAR), Osteoarthritis Research Society International, and National Institute for Health and Clinical Excellence (NICE) state that topical NSAIDs may be considered for patients with mild to moderate OA of the knee or hand, particularly in patients with few affected joints and/or a history of sensitivity to oral NSAIDs. In fact, the EULAR and NICE guidelines state that topical NSAIDs should be considered before oral therapies. Clinical trials of topical NSAIDs, most notably formulations of diclofenac and ketoprofen, have shown efficacy significantly superior to placebo and similar to oral NSAIDs. Most topical NSAIDs (piroxicam being the exception) have shown improved safety and tolerability compared with oral NSAIDs. Topical salicylates and capsaicin are available in the US without a prescription, but neither has shown substantial efficacy in clinical trials, and both have potential to cause serious AEs. Accidental poisonings have been reported with salicylates, and concerns exist that capsaicin-induced nerve desensitization is not fully reversible and that its autonomic nerve effects may increase the risk of skin ulcers in diabetic patients.

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Acknowledgements

Drs Altman and Barthel were involved in the conception, design, selection of search terms, drafting, critical revision and approval of the article. The authors’ work was independent of the funding source. Jeffrey Coleman, MA, and Robert Gatley, MD, of Complete Healthcare Communications, Inc. (Chadds Ford, PA, USA) contributed editorial support for this paper (literature search, document retrieval and translation, medical writing and copyediting) with funding from Endo Pharmaceuticals Inc. (Chadds Ford, PA, USA).

Dr Altman has received research grants from Novartis and Ferring; received consulting fees from Endo, Novartis, Ferring and Rottapharma; and participated in speakers’ bureaus for Ferring and Forest. Dr Barthel has no conflicts of interest relevant to the contents of this article.

The funding source did not participate in collection, analysis, or interpretation of the data or in the preparation, review or approval of the manuscript. A courtesy copy of the finished manuscript was sent to Endo Pharmaceuticals at the time of submission.

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  1. David Geffen School of Medicine, Department of Rheumatology and Immunology, University of California, 1000 Veteran Avenue, Los Angeles, CA, 90024, USA

    Roy D. Altman MD

  2. Private Practice, Santa Barbara, CA, USA

    H. Richard Barthel

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  2. H. Richard Barthel
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Correspondence to Roy D. Altman MD.

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Altman, R.D., Barthel, H.R. Topical Therapies for Osteoarthritis. Drugs 71, 1259–1279 (2011). https://doi.org/10.2165/11592550-000000000-00000

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