However, NSAIDs are more effective for knee OA pain relief compared with acetaminophen, with a 0.29 effect size in a 2011 meta-analysis.8 “If acetaminophen fails or doesn’t work well, this is one of your choices,” he said. NSAIDs’ cardiovascular risks, particularly for older patients, vary depending on the drug.9 Oral diclofenac is dangerous, he stressed. “It puts people at increased risk of heart disease, mostly in people who are older whose main mortality risk is heart disease. I don’t use it,” he said. Topical diclofenac is a safer option with no systemic risks. Naproxen does not increase heart disease risk in many studies. “It needs to be in your portfolio of treatment. Not that it doesn’t have other side effects. It does. But with respect to risk of heart disease, it is entirely safe,” he said.
Nabumetone has a comparatively benign risk of upper gastrointestinal bleeding, and celecoxib is also safer option.10 He prefers to prescribe celecoxib at less than 400 mg a day to avoid an increase in heart disease risk.11 Consider topical NSAIDs over oral forms, he said. “Given the inefficacy of acetaminophen, I think these will surpass acetaminophen as a recommendation in the future. They are benign and work, although not terribly well, but mainly for hand OA and knee OA.”