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Australian Journal of Pharmacy : April 2005
Dr Gowan also recommends the use of glucosamine supplements. ‘Glucosamine has good evidence and may be of value for people with osteo- arthritis, but consumers should be advised to take 750mg twice a day for a trial of about two months to assess benefit.’ A community pharmacy setting When asked for pain management advice by patients in a community pharmacy setting, pharmacists should keep in mind the TGA’s new recommendations regard- ing COX-2 inhibitors (www.tga.gov.au). Effective communication with the older person is required to assist with optimum management, says Dr Gowan. ‘If the person is returning for repeat prescriptions and they are currently tak- ing COX-2 inhibitors at doses above the recommended TGA guidelines (that is, greater than 200mg a day of celecoxib [Celebrex] or 15mg a day of meloxicam [Mobic, Movalis]), intervention is sug- gested, especially if they have cardiovas- cular risk factors. Pharmacists are advised to suggest to the consumer that either they make an appointment with their GP, or the phar- macy contacts the GP to confirm ongoing use in the doses previously prescribed,’ she said. Following last year’s withdrawal of Vioxx, many GPs have arranged recall of their patients to discuss ongoing pain management strategies. Pharmacists should ensure all patients have had their treatment reviewed in light of the new advice about all COX-2 inhibitors. ‘If paracetamol is used, a discussion about the use of therapeutic doses of paracetamol—often ordered by the GP but not taken—is the first measure. If conventional NSAIDs are ordered to replace the COX-2s, counselling advice should be offered as to the optimum use of these agents. For example, in some cases they may be able to be used prn to supplement paracetamol,’ says Dr Gowan. ‘Gastrointestinal, cardiac disease or renal impairment risk factors should also be considered. If agents such as tra- madol are selected, adverse effects and drug interactions must be considered.’ Remain up-to-date As a result of the Vioxx recall and the TGA’s announcements about all COX-2s, many patients will come into the phar- macy to ask questions, so pharmacists must be up-to-date with their knowledge. ‘Pharmacists must be aware of the TGA recommendations and any changes as soon as released, for example, the possi- ble reintroduction of Vioxx but with a black boxed warning statement,’ said Dr Gowan. ‘Pharmacists are advised to check the TGA site regularly to be aware of any changes.’ Dr Gowan also reminds pharmacists to explain to patients the reason for differ- ent approaches for different people, depending on their dosage, risk factors and other medications taken. ‘Reassurance is required with con- sumers to prevent unnecessary concern as many people have been taking these agents for some time without adverse effects. In addition, it is important that adherence to other essential medications (for example cardiovascular) is continued as some consumers are feeling concerned about other possible adverse events.’ Lifestyle factors Pharmacy academic Professor Peter Car- roll adds that lifestyle factors are a vital part of any pain management program. ‘It’s important to think of both non- pharmacological and pharmacological treatments,’ he said. ‘If the person is over- weight, try to reduce their weight so it takes the pressure off knees and joints, which will relieve symptoms. Tailor an exercise program that will increase mus- cle strength and bring stability back to joints.’ When it comes to pharmacological treatments, Professor Carroll says there is no debate. ‘Without doubt, the drug of choice for first-line treatment of osteoarthritis is paracetamol—it works, and it doesn’t have the side effects of some other treatments. The problem is com- pliance—people don’t like taking two tablets, four times a day, or they forget. Some patients will say they tried parac- etamol and it didn’t work—that’s because they’ve taken one tablet, three times a day—so it’s important to ask how much they’ve been taking. If they’re tak- ing the full therapeutic dose and it’s not working, then it’s fair to add something else,’ he said. ‘If you do have to use a non-steroidal anti-inflammatory drug, look at the prob- lems the patient may have, such as car- diovascular disease or other risk factors. Then, if appropriate, you can think of adding an NSAID, but only for the short- est period of time. With COX-2 inhibitors, such as Celebrex and Mobic, you really do need to look at the TGA guidelines. These should only be used when other treatments are not working and for the shortest possible time. It also depends on the patient’s other medications.’ Professor Carroll agrees with Dr Gowan that glucosamine is worth recom- mending to patients with osteoarthritis. ‘For a complementary therapy, there is good evidence that glucosamine does improve symptoms. Patients must take it for a couple of months to get the full effects, and there is evidence that in the longer term it does improve joint func- tion. After two to three years it can show positive changes in the joint.’ ...lifestyle factors are a vital part of any pain management program As Professor Carroll concludes: ‘If you’re looking to treat people with osteoarthritis “after Vioxx”, you must look at the non-pharmacological options—exercise and supportive thera- pies such as physiotherapy. There is no question, paracetamol should be the lynchpin of treatment, and glucosamine if you want a complementary therapy. NSAIDs and COX-2 inhibitors can be added if necessary, taking into account the patient’s known risk factors.’ Confusing COX-2 conundrum Not everyone is raging against the COX- 2 inhibitors. Professor Jim Bertouch, chairman of the Department of Rheuma- tology at Prince of Wales Hospital and chairman of the Therapeutics Commit- tee of the Australian Rheumatology Association, says the TGA’s new require- ments are confusing and he wonders why the changes were made at all. Professor Bertouch questions why the TGA does not publicly release the information sup- plied by the drug manufacturers, and says THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 APRIL 2005 ? 253