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The article presents new views on the treatment of pain syndromes in musculoskeletal diseases, in particular in osteoarthritis (OA) of various localizations (gonarthrosis, coxarthrosis). New recommendations (2019)(2020) of international societies for the study of symptomatic delayedacting drugs (SYSADOA) and their use in the treatment of OA are presented. We present the opinions of experts from different communities: the

Diseases of the peripheral joints (osteoarthritis OA) and the spine are the most common pathology among other chronic conditions. One of the most common diseases characterized by degenerative periarticular changes with various clinical manifestations is periarthritis. Unlike OA, periarthritis is characterized by a discrepancy between active and passive movements, increased pain during strictly defined movements, the absence of joint swelling or local swelling in the projection of the affected tendon. As the basic therapy of OA (step 1), it is recommended to prescribe locally nonsteroidal anti-inflammatory drugs (NSAIDs), as drugs with less systemic adverse effects. Local NSAIDs have a sufficient analgesic effect in knee joints OA. Among topical NSAIDs for reducing pain in knee joints OA and periarticular tissues, diclofenac gel (Voltaren Emulgel 2%) is approved for use, the effectiveness of which has been demonstrated in many studies. To achieve maximum effect, the gel is applied according to the instructions for use of the drug: 2 ml on the anterior, posterior and lateral surfaces of the knee 2 times a day (every 12 hours) for 4 weeks.

Chronic pain continues to remain one of the urgent problems of modern medicine. From 15 to 25% of the adult population suffers from chronic pain. Medical treatment includes the appointment of non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. The greatestform for the appointment of NSAIDs is the topical form. According to the recommendations of International and National societies for the treatment of pain syndrome, osteoarthritis (OA) therapy are recommended to start with topical NSAIDs, as drugs with less systemic adverse side effects (NSAIDs).Topical NSAIDs have proven analgesic and antiinflammatory efficacy in the treatment of diseases of the musculoskeletal system, musculoskeletal pain, but have a low risk of developing systemic NSAIDs in comparison with oral forms, which expands the possibilities of their appointment in patients with comorbid pathology (diseases of the gastrointestinal tract, cardiovascular risks).Among NSAIDs, diclofenac is the "gold standard" of analgesia. After topical application, diclofenac penetrates through the skin and further into the deeper underlying tissues while maintaining sufficient concentration to provide a therapeutic effect. The topical form of diclofenac – diclofenac diethylamine 2%, when used correctly, can cause an analgesic effect comparable to the oral form. This topical form has a high clinical efficacy in the treatment of acute musculoskeletal pain (sprains), the course of therapy takes 1 week, for chronic pain syndromes (knee OA or hand) the course of therapy is from 2 to less than 6 weeks. The clinical efficacy of diclofenac diethylamine monotherapy is comparable to that for complex therapy in combination with oral forms of NSAIDs, while having good tolerability.

Osteoarthritis (OA) is the most common joint disease globally, and its incidence increases with age – up to 80–90% in people over 60 years. There is a high comorbidity between OA and cardiovascular diseases (CVD), such as arterial hypertension (AH), atherosclerosis, and coronary heart disease (CHD). The main objectives of OA therapy include pain reduction, cartilage matrix preservation, safe profile in patients with comorbid diseases, minimal adverse effects. In addition, the drug should be comparable in analgesic effects with nonsteroidal anti-inflammatory drugs (NSAIDs). Such drugs include structural-modifying agents – symptomatic slow-acting drugs for osteoarthritis (SYSADOA), one of which is chondroitin sulfate (CS). According to the 2019–2020 International and Russian guidelines, only pharmaceutical-grade CS is recommended for use. The high efficacy of intramuscular administration of CS in patients with OA, lower back pain, and comorbid diseases (AH, CHD, atherosclerosis) has been proven. CS is prescribed for a long treatment course – up to two months.

More than 500 million people worldwide suffer from osteoarthritis (OA). Neck and low back pain (LBP) is one of the most common reasons for visiting a general practitioner to receive primary medical care in different countries. The prevalence of chronic LBP varies from 4% to 20%, and increases linearly from the third decade to 60 years, and stabilizes in the seventh decade of life. According to the latest published clinical guidelines of the Russian Association for the Study of Pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are used in minimally effective doses and a short course to relieve acute musculoskeletal pain. The ratio of the NSAIDs activity associated with cyclooxygenase (COX) – COX-1 / COX-2 – inhibition allows us to evaluate their potential toxicity. The smaller this value, the more selective the drug is against COX-2, and the less toxic it is. Meloxicam belongs to the predominantly selective COX-2 inhibitors. In the Russian market, meloxicam of domestic production - Amelotex® is widely prescribed. Several studies have shown the high efficacy and safety of meloxicam in the treatment of pain syndromes with different localizations (LBP, neck pain of vertebrogenic nature, OA, etc.), it can be recommended for elderly patients, patients with comorbid diseases such as arterial hypertension (AH), diabetes mellitus, gastrointestinal tract pathology. Meloxicam has a good efficacy and safety profile, a pronounced symptom-modifying effect.

The issue nonsteroidal anti-inflammatory drugs (NSAIDs) use safety is associated with a high frequency of adverse events (AEs) from the gastrointestinal tract and cardiovascular risks. Patients with lower back pain (LBP) and osteoarthritis (OA), as a rule, have comorbid diseases, such as arterial hypertension (AH), coronary heart disease (CHD), gastrointestinal tract (GIT) diseases, which significantly complicates the appointment of NSAIDs. The main guideline in NSAIDs appointment is the selective ability to inhibit cyclooxygenase-1 and -2 (COX). The ratio of the activity of NSAIDs when blocking COX-1/COX-2 allows us to judge their potential toxicity. And, then higher the selectivity of NSAIDs, then lower its toxicity. For example, the ratio of COX-1/COX-2 in meloxicam is 0.33, diclofenac – 2.2, tenoxicam – 15, piroxicam – 33, indomethacin – 107. To the predominantly selective COX-2 NSAIDs include meloxicam, which has little effect on the GIT, the lowest relative risk (RR) of complications from the cardiovascular system (CVS). The therapeutic efficacy of meloxicam is comparable to piroxicam and diclofenac. A number of studies have shown the high efficacy of meloxicam, both with per oral (p/o) administration (7.5–15 mg/d), and with intramuscular (i/m) administration (1.5 ml), and when injected into trigger zones. Both with p/o and the injectable form of meloxicam has minimal GIT AEs and absence local reaction in the injection area. The drug can be recommended both as a combination therapy and prescribed in monotherapy.