The role of anti-inflammatory drugs in the treatment of osteoarthritis: a United States viewpoint.

Guidelines for the treatment of osteoarthritis (OA), first published in 1995 under the auspices of the American College of Rheumatology, were updated with publication of revised recommendations in September 2000 to take account of significant advances in OA management. These advances include increased understanding of the disease process and the introduction of new medications, including the cyclooxygenase-2 (COX-2) selective inhibitors and the intra-articular hyaluronans. In addition, studies demonstrating superior efficacy of non-steroidal anti-inflammatory agents (NSAIDs) vs acetaminophen in the treatment of OA led to a re-evaluation of indications for initial pharmacologic approaches, given the availability of safer NSAIDs. In contrast to the previous recommendation that acetaminophen was the drug of choice for the initial treatment of all patients with OA, the new recommendations support consideration of the use of NSAIDs as initial treatment--either COX-2 selective inhibitors or classical NSAIDs with gastroprotective agents--particularly in patients with moderate to severe pain and inflammation. The important role of non-pharmacologic approaches including weight loss, avoidance of joint overuse, appropriate exercises and orthotics was re-emphasized. It is anticipated that guideline revisions will take place at more frequent intervals in the future, given today's rapid advances in therapeutic approaches, not only for symptomatic therapy but also for therapy targeted to structural disease modification.