When are NSAIDs appropriate in osteoarthritis?

Osteoarthritis is a multifactorial disease that is more common in the elderly than in younger individuals. Opinion is divided on whether it is a degenerative or inflammatory process. Most rheumatologists accept that the disease has an inflammatory component, particularly when it is complicated by crystal deposition. Nonsteroidal anti-inflammatory drugs (NSAIDs) are particularly toxic in the elderly. The geriatrician should use a more conservative approach to initial therapy, which should include patient education, physiotherapy and even the consideration of intra-articular steroid injections. If systemic drug therapy is still required, simple analgesics should usually be tried first. If NSAIDs are then required, they can be selected according to their chemical structure (which bears some relation to adverse effects) or half-life (which is more relevant to optimum prescribing). Propionic acid derivatives are well established and remain the NSAIDs of choice: agents with a short half-life, perhaps given in low dosages, are preferred. The use of topical formulations, which are more expensive, may avoid some adverse effects; however, drug effects are unlikely to remain truly localised. It may be prudent to provide gastroprotective therapy for some elderly patients. A full evaluation of the new generation of cyclooxygenase-2 inhibitors in osteoarthritis is still awaited.