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According to modern ideas, pain is a multidisciplinary problem with serious medical and socio-economic importance. The most common pain occurs in various structures of the musculoskeletal system. It is noted that the universal mechanism of acute and chronic pain is inflammation, which requires therapy with nonsteroidal anti-inflammatory drugs (NSAIDs). Data on the effectiveness and good tolerability of local NSAIDs are presented. The latest recommendations of the international Committee ESCEO 2019 on the management of patients with osteoarthritis (OA), which confirms the effectiveness and safety of local forms of NSAIDs, in connection with which, ESCEO recommends their use in elderly patients, in patients with comorbid conditions and at high risk of adverse reactions. It is also envisaged to use these drugs for the treatment of OA before the appointment of systemic NSAIDs. The results of randomized clinical trials (RCTS) and meta-analyses confirming clinical efficacy and safety in the treatment of acute and chronic pain by one of the representatives of local NSAIDs-diclofenac sodium gel are presented. Diclofenac sodium gel has been shown to be more effective than placebo in the treatment of acute and chronic pain. Good tolerability of the drug was observed in patients in different age groups, including patients older than 65 years, and in patients with comorbid conditions. The results obtained indicate the effectiveness and good tolerability of diclofenac sodium gel, including long-term, and allow the drug to be widely used as symptomatic therapy for the treatment of acute and chronic pain, including in elderly patients and patients with comorbid conditions.

Widespread osteoarthritis (OA) and high related disability rates determine not only the medical, but also socioeconomic significance of this disease. In recent years there has been a tendency to increase the incidence of OA. According to the current concepts, inflammation plays a leading role in the development of chronic pain in OA, which requires adequate anti-inflammatory therapy. There are data on the diverse mechanisms of action of the nonsteroidal anti-inflammatory drug (NSAID) nimesulide and results from clinical trials and metaanalyses, which confirm its efficacy and good tolerability. Several clinical trials covering 22,938 patients with OA have indicated that the overall frequency of adverse reactions (AR) from nimesulide is 8.2%. There is evidence on the efficacy and good tolerability of topical NSAIDs, as well as combination drugs containing glucosamine sulfate and chondroitin sulfate, the use of which together with oral drugs enhances the efficiency of treatment without increasing the risk of ARs.

The paper highlights data on the mechanisms of action and efficacy of aceclofenac in chronic inflammatory diseases of the joint and spine (rheumatoid arthritis, spondyloarthritis) and osteoarthritis (OA). It shows the comparable efficacy of aceclofenac and nonselective nonsteroidal anti-inflammatory drugs in different rheumatic diseases. Randomized controlled trials and meta-analyses have revealed the high gastrointestinal safety of aceclofenac, which is comparable with that of celecoxib, including the low risk of gastrointestinal bleeding. Since aceclofenac has no negative effect on the articular cartilage and has a good tolerability, it may be given to persons of any age, including long-term use, which does not affect the safety of treatment.

The paper gives data on the prevalence of osteoarthritis (OA) and the rate of comorbidities in this disease. It discusses problems of adequate and safe therapy in these patients. The basic provisions of the 2015 clinical guidelines for the rational use of nonsteroidal antiinflammatory drugs (NSAIDs), as well as assessment of risk factors for NSAID-related complications are presented. The place of symptomatic slow-acting drugs for OA (SYSАDOA) and a clash of opinions as to their efficacy among different national or international communities of specialists are discussed. The 2014 ESCEO International Committee guidelines for the management of OA patients, which confirm the necessity of prescribing SYSDOA as initial treatment, are presented. The properties and function of synovial fluid in health and OA are depicted. Clinical and experimental findings have shown that, by improving the lubricating properties of synovial fluid, exogenous hyaluronon has many anticatabolic and anabolic effects and affects pathogenetically significant factors in OA. The results of randomized clinical trials (RCTs) comparing hyaluronans of different molecular weight are given. There are data of RCTs on the clinical efficacy and structuremodifying activity of hylan G-F 20 and on its significant pain relief in OA patients. The paper demonstrates benefits in surviving the analgesic effect of hylan G-F 20 versus intraarticular administration of glucocorticoids.

Objective. To evaluate the symptom- and structure-modifying effect of Alflutop compared to placebo (PL) in patients with knee osteoarthritis (OA). Material and methods. The study included 90 patients with knee OA (according to the criteria of the Russian Association of Rheumatologists) at the stage 2–3 (according to the Kellgren-Lawrence scale); pain score when walk- ing ≥ 40 mm (assessed using the visual analog scale). All the patients provided an informed consent. The patients were randomly divided into two groups: group 1 (n=45) received an intramuscular injection of 1 mL Alflutop for 20 days with 6-month intervals for 2 years (a total of 4 courses for 2 years); group 2 (n=45) received an injection of PL (iso- tonic sodium chloride solution) in the same way. Ibuprofen at a dose of 600–1200 mg/day was administered as con comitant therapy. To evaluate the structure-modifying effect of Alflutop, X-ray of the knee joint was performed at the beginning and end of the study; the level of biochemical markers (CTX-II and COMP) was determined at the beginning, after 3 months, and at the end of the study. A statistical analysis was performed using the Statistica 10 software package. Results. After the 2-year follow-up, a statistically significant negative trend was detected less frequently in the group of patients treated with Alflutop compared to the PL group (6.1 and 38.4%, respectively). The statistically significant delay in joint space narrowing was observed in patients who received Alflutop in contrast to patients who received PL (the numerical score of the joint space, the Wilcoxon test; p=0.0003). An increase in osteo- phyte size was observed in 72% of the patients receiving PL, and only in 27% of the patients receiving Alflutop (medial and lateral osteophytes of the femoral bone, the Wilcoxon test; p=0.0078; medial and lateral osteophytes of the shin bone, the Wilcoxon test; p=0.0001 and p=0.0039, respective- ly). Augmentation of subchondral osteosclerosis was determined more often in the PL group (the McNemar's test; p=0.0313). The level of the marker of cartilage degradation CTX-II tended to decrease after 3 months of Alflutop therapy, which has persisted until the end of the study. This indicates a decrease in the articular cartilage degradation. In the PL group, the CTX-II level remained unchanged. A tendency to an increase in the level of the marker of cartilage degradation COMP was found in the PL group. Conclusion. Based on double-blind, placebo-controlled, randomized study, the structure-modifying effect of Alflutop in knee OA has been proved. Alflutop delays the radiographic progression of knee OA, joint space narrowing and osteophyte growth, and reduces the degradation of the articular cartilage matrix.