Expert consensus on S-etodolac in the management of osteoarthritis from an Indian perspective

Osteoarthritis (OA) is the most frequent joint disease in India. The current treatment guidelines suggest nonsteroidal anti-inflammatory drugs (NSAIDs) for the management of OA based on the patient's risk profile. Etodolac, a preferential cyclooxygenase 2-selective, chiral NSAID, has a long and well-established record of being an effective therapy for acute musculoskeletal pain, OA, and rheumatoid arthritis. Studies have shown that the pharmacological properties of R and S-enantiomers of etodolac differ profoundly; S-Etodolac is responsible for the majority of the anti-inflammatory activity, whereas the R-form is almost inactive. The objective was to develop evidence-based practical consensus recommendations for the management of OA with chirally pure S-Etodolac in the Indian settings. Literature review was carried out from the PubMed Database to identify relevant articles between January 1980 and May 2022 using keywords such as “osteoarthritis,” “NSAIDs,” “Etodolac,” “chirality,” “S-Etodolac,” “consensus,” and “management.” Extensive literature review was done. Further, a committee of 13 orthopedic specialists from India with significant experience in managing patients with OA was constituted. The key areas of discussion were as follows: (i) Selection of medications; (ii) role and risk/benefit profile of etodolac versus other NSAIDs; (iii) patient subgroups who would benefit from S-Etodolac oral therapy; and (iv) S-Etodolac gel in the management of OA. Experts strongly recommended S-Etodolac therapy in OA patients at increased risk of NSAID-related gastrointestinal complications, cardiovascular risk, and renal impairment. The patient pool that would derive maximum benefit from a combination of S-Etodolac and paracetamol therapy includes: (i) OA patients with the acute phase of the disease with reactive synovial effusion or acute painful inflammatory arthritis; (ii) moderate pain; and (iii) acute exacerbation of OA. This article can guide medical practitioners in clinical decision-making while choosing an appropriate NSAID therapy for the management of OA.