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‘Provocative’ New Study Calls into Question the Best Medicines for Knee Pain


People with arthritis who take anti-inflammatory medications, like ibuprofen and naproxen, to get relief from painful knees may be harming their joints, a new study suggests.

MRI scans from more than 1,000 patients with osteoarthritis in their knees revealed that long-term use of NSAIDs (non-steroidal anti-inflammatory drugs) may lead to increased joint inflammation and damage to cartilage, researchers reported Monday at the annual meeting of the Radiological Society of North America.

Osteoarthritis is the most common type of arthritis, usually affecting the hands, hips or knees. It occurs when the cartilage in a joint erodes and the bone changes, causing pain, stiffness and swelling, according to the Centers for Disease Control and Prevention. About 32.5 million American adults are living with the condition.

“We were surprised by the findings,” the study’s lead author, Dr. Johanna Luitjens, a postdoctoral scholar in the department of radiology and biomedical imaging at the University of California, San Francisco, tells TODAY.com. “We actually thought we would see the opposite of those outcomes with people who take NSAIDs having less inflammation.”

It’s not clear why NSAIDs might lead to more joint damage, Luitjens says. And earlier studies have been mixed on the topic of whether NSAIDs reduce or increase inflammation, she adds.

To take a closer look at the impact of NSAIDs on joint health in those with osteoarthritis, Luitjens and her colleagues turned to the Osteoarthritis Initiative, a 10-year observational study sponsored by the National Institutes of Health. Some 277 of the participants had moderate to severe osteoarthritis and had taken NSAIDs for at least a year. Their scans were compared to those of the 793 participants who did not take NSAIDs.

There were some differences between the groups at the outset, such as worse inflammation and cartilage damage among those who were taking NSAIDs. When Luitjens and her colleagues compared the initial scans from the two groups of arthritis patients to those taken four years later, the researchers found that there was significantly more inflammation in participants taking NSAIDs, which was surprising because the NSAIDs are anti-inflammatory medications.

The researchers also saw more degenerative changes and reduction in cartilage thickness in the participants who regularly used NSAIDs, but those findings were not statistically significant, meaning that they could be due to chance.

“I think we really need a discussion on the long-term effects of NSAIDs,” Luitjens says. “They are so commonly used. And ultimately I think we need a prospective randomized study to provide conclusive evidence of the anti-inflammatory impact of NSAIDs.”

The new study is “very provocative,” Dr. Anca Askanase, associate director of the division of rheumatology at the Columbia University Irving Medical Center, tells TODAY.com.

While Askanase thinks people should be cautious when taking NSAIDs because of potential side effects, the new study does not make her more worried about her patients taking them.

“The American College of Rheumatology guidelines are based on what works for osteoarthritis of the knees, hips and hand, and they still give NSAIDs their highest recommendation for pharmacologic measures,” Askanase says. “While these data give me pause — and I think that would be more than just me — I don’t think we have enough evidence that they might actually hasten the progression of osteoarthritis.”

Currently there are no drugs that actually treat the underlying disease, Askanase says. “In terms of symptom relief, NSAIDs are considered the first go-to, the safest alternative,” she adds. “I’m not ready to throw them out because there is not much else to offer patients.”

There’s been a lot of debate surrounding NSAIDs, Dr. Mariam Zakhary, an assistant professor of sports medicine at the Icahn School of Medicine, tells TODAY.com. “There are so many things to take into account.”

For example, the researchers allowed that the NSAID group started out in worse shape than the comparison group, so “these patients were already prone to worse outcomes,” she says.

But the impact of NSAIDs on joint health isn’t the only issue with the medications, Zakhary says, adding that they can have many adverse effects systemically, such as increased risk of heart disease and damage to the stomach and the kidneys.

That’s because the medications block the enzymes COX-1, which protects the stomach lining and the kidneys, and COX-2, which is involved in inflammation. There is another choice, COX-2 inhibitors, which selectively target inflammation and spare the stomach and the kidneys, but still are linked to hypertension and heart issues.

Zakhary would prefer patients to not be on NSAIDs long term, but rather take them to ease pain while patients participate in a rehab program to strengthen muscles around the knee.

She also feels that the current study isn’t strong enough to change recommendations on NSAIDs.

“This is a good start, and it tells us we need to continue looking into it,” Zakhary says. “For now, patients should just worry about systemic effects, and they should talk to their doctor about the different types of NSAIDs.”

This article was originally published on TODAY.com



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