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Topical NSAIDs in OA — SCE Rheumatology MCQ

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ModerateOsteoarthritisTopical NSAIDs in OASCE Rheumatology

A 60-year-old man with symptomatic hip osteoarthritis asks whether a topical NSAID gel is likely to provide the same joint-specific benefit as it does in knee osteoarthritis. According to the NICE evidence review, what is the main pharmacological limitation of topical NSAIDs at the hip?

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Correct answer: C — Topical formulations are unlikely to penetrate adequately to a proximal, deep joint

The correct answer is C. The hip is a proximal, deep joint, and NICE's evidence review notes that topical formulations are unlikely to penetrate sufficiently to such joints. Evidence of clinically important benefit from topical NSAIDs was principally derived from knee osteoarthritis. However, NICE does not categorically prohibit their use in hip osteoarthritis: NG226 says to offer a topical NSAID for knee OA and consider one for OA affecting other joints. If topical treatment is ineffective or unsuitable, an oral NSAID may be considered after assessing gastrointestinal, renal, hepatic and cardiovascular risk, with gastroprotection. Topical NSAIDs are available in the UK; there is no established hip-specific chondrotoxicity, equivalence with oral intra-articular exposure, or interaction with arthroplasty materials.

Reference: National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management. NG226, recommendations 1.4.2–1.4.4 and Evidence review I, 2022. https://www.nice.org.uk/guidance/ng226/evidence/i1-clinical-and-cost-effectiveness-of-oral-topical-and-transdermal-medicines-for-the-management-of-osteoarthritis-pdf-405016302420