Can a nurse-directed intervention reduce the exposure of patients with knee osteoarthritis to nonsteroidal antiinflammatory drugs?

Objective: : The objective of this study was to evaluate a nurse-directed self-management intervention for managed care patients with knee osteoarthritis (OA), emphasizing nonpharmacologic (NonPharm) management of pain and functional impairments and minimization of exposure to the risks and costs of nonsteroidal antiinflammatory drugs (NSAIDs).

Methods: : Subjects were 186 patients from a large health maintenance organization (HMO) who satisfied American College of Rheumatology clinical criteria for knee OA. Two of 4 HMO sites (and their patient cohorts) were randomly assigned to the education group; the other 2 served as a delayed-intervention control group. At each location of care for the education group, an arthritis nurse educator, in consultation with the patient's primary care physician (PCP), followed a detailed algorithm for implementing and monitoring the response to NonPharm treatment modalities (eg, quadriceps strengthening exercises, counseling in principles of joint protection, use of thermal modalities). The nurses apprised the PCP of the patient's progress and made algorithm-based recommendations, as appropriate, for reduction of dose, and eventual discontinuation, of NSAIDs in favor of acetaminophen. Outcomes (measured at baseline, 3, 6, and 12 months) included pain and function scales from the Western Ontario and McMaster Universities (WOMAC) OA Index.

Results: : The treatment groups were similar at baseline with respect to sociodemographic and clinical characteristics. Medical record audits revealed that NonPharm treatments (most often exercise) were implemented by 75% of patients in the education group but by only 18% of patients receiving routine care (P < 0.00001). Over the subsequent 12 months, 20 patients (26%) in the education group, but only 3 (5%) in the control group (P = 0.002), underwent changes in drug treatment of OA pain consistent with the NSAID-sparing goals of the intervention, ie, acetaminophen as initial drug of choice; reduction in dose, or discontinuation, of NSAID; switch from an NSAID to an analgesic. Only one patient in the education group required reinstitution of NSAIDs because of an increase in knee pain. Mean WOMAC scores indicated no deterioration of pain control or function over 12 months in the group treated according to the algorithm.

Conclusion: : Incorporation into the primary care setting of self-care education for patients with knee OA, with collaboration between a proactive arthritis nurse and the patient's PCP, can reduce reliance on NSAIDs without a resultant increase in OA pain and disability.