Evidenzbasierte Therapie degenerativer Gelenkerkrankungen: Teil 2: Medikamentöse Therapien

Zusammenfassung

Medikament der ersten Wahl in der Therapie der Arthrose ist Paracetamol, da es das beste Nutzen/Risikoprofil besitzt. Nicht steroidale Antirheumatika (NSAR) sind etwas stärker analgetisch wirksam und besitzen zudem eine antiphlogistische Komponente, ihr Einsatz sollte jedoch zeitlich immer eng begrenzt sein und im Wesentlichen der akut-entzündlichen Arthritis vorbehalten bleiben. Mittel der Wahl ist hierbei Diclofenac. Gemäß der derzeitigen Datenlage sollte bei Patienten mit einem erhöhten Gastrointestinalen Risiko eine Kombinationstherapie aus einem traditionellen NSAR und einem Protonenpumpenhemmer erfolgen. Alternativ können Coxibe zum Einsatz kommen, sofern keine Kontraindikationen vorliegen. Coxibe und traditionelle NSAR - außer dem ASS und eventuell dem Naproxen - sind mit einem erhöhten kardiovaskulären Risiko assoziiert. Daher sollten diese Substanzen bei Patienten mit kardiovaskulären Risikofaktoren nicht oder nur nach strengster Indikationsstellung zum Einsatz kommen. Opiode haben bei kritischer Indikationsstellung ihre berechtige Stellung in der Arthrosetherapie. Sie sollten Bestandteil eines Schmerzregimes sein, das ein Schmerztagebuch und regelmäßige Reevaluationen beinhaltet. Wichtig ist, dem Patienten das Ziel der medikamentösen Therapie, die Aufrechterhaltung der für die Gelenkfunktion bedeutsamen körperlichen Aktivität deutlich zu machen. Aufgrund der häufigen Selbstmedikation und der Inanspruchnahme von alternativmedizinischen Heilverfahren sollten auch diese Elemente im Therapiekonzept berücksichtigt werden. Ebenso wie eine begleitende Depression, die wie bei vielen chronischen Erkrankungen auch unter Arthrosepatienten gehäuft auftritt.

Abstract

First-choice medication in the therapy of osteoarthritis is paracetamol since it offers the best benefit/risk profile. Non-steroidal anti-inflammatory drugs (NSAIDs) are slightly more effective analgesics and offer an additional antipyretic component. Nevertheless, their usage should always be strictly limited temporally and reserved to the treatment of acute inflammatory osteoarthritis. In that case, first-choice medication is diclofenac. Regarding current study results, patients with an increased gastrointestinal risk should be treated with a combination therapy composed of a traditional NSAID and a proton pump inhibitor. Alternatively, COX-2 inhibitors might be used if there are no contraindications. COX-2 inhibitors and traditional NSAIDs - with the exception of aspirin and possibly naproxen - are associated with an increased cardiovascular risk. Therefore, patients with cardiovascular risk factors should not be treated with those substances or only after a rigorous examination of indication. A critical indication qualifies opioids to treat osteoarthritis. They should be part of a pain regimen which contains a pain diary and regular evaluations. It is important for the patient to illustrate the aim of the drug therapy, the maintenance of physical activity which is vital for joint functioning. Since patients often use over-the-counter medication and alternative medicine, these elements should also be considered within the therapeutic concept. As well as a comorbid depression which prevalence is - as it is in many other chronic diseases - increased among patients with osteoarthritis.

Schlüsselwörter

Arthrose - nicht steroidale Antirheumatika (NSAR) - Schmerztherapie

Key words

Osteoarthritis - non-steroidal anti-inflammatory drug (NSAID) - pain treatment

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