The choice of analgesic treatment is based on a precise estimate of the pain. The severity of pain must be taken into account in order to prescribe a suitably effective analgesic. The recommended first-line analgesic is paracetamol up to 3 grammes per day.
Repeated doses are necessary for good efficacy, which must be explained to the patient. Its tolerance is good. In the event of renal insufficiency or chronic alcoholism, doses should be adjusted accordingly.
Non-steroidal anti-inflammatory drugs and Coxibs
NSAIDs should be reserved for second-line use in the event of failure of the paracetamol and/or in case of an inflammatory flare-up. They should always be prescribed and used at the lowest effective dose and for the shortest possible time.
The choice of NSAID must be made taking into account its safety profile and the individual risk factors for the patient.
Conventional NSAIDs or Coxibs should not be prescribed in the event of a peptic ulcer or gastrointestinal bleeding, a history of gastrointestinal bleeding or perforation occurring during a treatment with NSAIDs.
NSAIDs being capable of inducing acute renal insufficiency, one must be particularly attentive to patients treated with diuretics, at risk of hypovolemia or impaired renal function.
In patients with known ischemic heart disease, peripheral arterial disease and/or a history of stroke (including transient ischemic attack), coxibs are contraindicated and non-selective anti-inflammatory drugs should be used with caution after a thorough evaluation.
Symptomatic slow-acting drugs in osteoarthritis
In several studies regarding knee and hip osteoarthritis, SYSADOAs showed efficacy on pain and functional disability. They work after a period of several weeks.
Some of them have a remnant effect of 1 to 2 months on stopping them and significantly reduce the consumption of NSAIDs.
In cases of unremitting pain, intolerance to paracetamol or contraindications to NSAIDs, it is possible to use level 2 and 3 analgesics of the WHO (weak and strong opioids).
They can enable getting through a painful period but at the cost of frequent undesirable side effects (nausea and vomiting, disorders of higher functions, severe constipation).
Their indication and their risk/benefit ratio must be thoroughly assessed.