What You Need to Know About Arthritis Medication
Several effective medications are available to relieve osteoarthritis-related pain. Oral medications are used most often, but research linking some to an increased risk of heart disease has made doctors less inclined to prescribe them first. Some people find that injections into the affected joint, or topical products applied to the skin surrounding a painful joint, also help reduce pain.
Although pain relievers can make you feel better, they cannot cure your osteoarthritis. Researchers, however, are working on identifying medications that can reverse or prevent worsening of the condition.
Oral pain relievers
Taking an oral pain medication is sometimes the first step in the medical treatment of osteoarthritis.
The most commonly used pain relievers are acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs). Which type of medication your doctor recommends depends on the intensity of your pain and the potential side effects of the medication. The drug with the fewest potential side effects is usually tried first. If this drug doesn’t relieve pain adequately, other pain medications can be added or substituted.
It is important to note that the American Heart Association has issued guidelines recommending that doctors not prescribe NSAIDs or COX-2 inhibitors (a newer generation of NSAIDs) to patients at risk for having a heart attack—including those with established coronary heart disease or risk factors, such as high blood pressure or high cholesterol—until they have tried other methods of relieving a patient’s pain.
This over-the-counter medication is the initial drug of choice for osteoarthritis because it is just as effective as most NSAIDs and is less likely to cause side effects, such as stomach irritation. It is also inexpensive. Because inflammation plays only a minor role in osteoarthritis, the anti-inflammatory effect of an NSAID usually is not required.
The maximum recommended daily dosage of acetaminophen is 4,000 milligrams (mg), generally taken as 325 to 650 mg every four hours up to 6 times a day.
Because acetaminophen is often an ingredient in other medications, such as cold remedies, it’s easy to consume too much if you’re not careful. Acetaminophen can cause liver damage if you take it at dosages exceeding the recommended amount.
Acetaminophen may be harmful for people who drink large amounts of alcohol. To help prevent liver damage, you should avoid consuming alcoholic beverages while taking this medication. Acetaminophen may also be dangerous if you are taking the blood thinner warfarin (Coumadin). Although acetaminophen appears to be associated with a slightly lower risk of heart disease than NSAIDs, if you use it on a regular basis you should see your doctor periodically to be monitored for adverse effects.
If acetaminophen fails to control your pain, NSAIDs are the next option. (See the chart on pages 18–21.) Aspirin, the original NSAID, is effective and inexpensive and may actually reduce the risk of heart disease. Other NSAID choices include ibuprofen (Advil, Motrin), naproxen (Aleve) and ketoprofen.
If you need an NSAID other than aspirin, the American Heart Association recommends starting with naproxen. If necessary, your doctor may prescribe a stronger NSAID such as diclofenac (Voltaren) or nabumetone.
Because inflammation is generally not a major problem in osteoarthritis, NSAIDs are used primarily as pain relievers in this circumstance.
How well osteoarthritis symptoms respond to a specific NSAID varies greatly from person to person. As a result, finding the right drug depends largely on trial and error. It can take at least two weeks of treatment to know whether the drug is effective.
Regular use of NSAIDs may cause stomach irritation, bleeding and ulceration because the drugs interfere with the formation of the protective mucus that normally coats the stomach. In fact, some degree of gastrointestinal bleeding occurs in more than 50 percent of NSAID users.
If you develop gastrointestinal discomfort or blood in your stools while taking an NSAID, call your doctor.
To reduce the risk of gastrointestinal problems, your doctor may recommend taking a traditional NSAID that is less likely to affect your stomach (for example, enteric-coated aspirin, which dissolves in the intestine rather than the stomach) or a traditional NSAID in combination with a drug that helps protect your stomach. Misoprostol (Cytotec) is approved by the Food and Drug Administration (FDA) for this use, but your doctor may prescribe others.
If you are over age 60, take corticosteroids, have a history of stomach ulcers or adverse reactions to NSAIDs, or have heart disease, diabetes or liver or kidney problems, you should be carefully monitored while you are taking NSAIDs or you should avoid them completely.
Many doctors now recommend topical NSAIDs for people at increased risk for adverse effects from oral NSAIDs. Regular monitoring can detect liver and kidney problems in their early stages, before they become serious. Your doctor may also monitor your blood pressure, blood counts and potassium levels during long-term NSAID treatment. If you take oral diabetes drugs or warfarin, be vigilant while using an NSAID, because it can increase the effects of these drugs. NSAIDs, especially aspirin, can also worsen asthma.
Developed in the 1990s, COX-2 inhibitors were a new type of NSAID at the time that avoided some of these side effects. But two of them, rofecoxib (Vioxx) and valdecoxib (Bextra), were withdrawn from the market after being linked to an increased risk of cardiovascular problems. The FDA continues to have concerns about the cardiovascular safety of celecoxib (Celebrex), a third COX-2 inhibitor that is still available.
The medication carries a strong warning on its label stating that it is associated with an increased risk of heart attacks and strokes and should not be taken by people who have recently had heart surgery. Many physicians reserve Celebrex for people who either do not benefit or who have adverse effects from other pain relief alternatives and are at low risk for heart attacks and strokes. Typically in such cases, the lowest effective dose is used for the shortest time possible. More recent evidence shows that nearly all NSAIDs pose cardiovascular risks, and their labels also warn of the potential for this adverse effect.
If you have severe osteoarthritis and find that acetaminophen or NSAIDs do not provide sufficient pain relief and you are not a candidate for joint replacement, your doctor may prescribe an oral opioid pain reliever. An opioid may also be prescribed if you are at increased risk of side effects from NSAIDs. Some examples of opioids are codeine and hydrocodone. Opioids are also sold in combination with acetaminophen, such as oxycodone with acetaminophen (Percocet). All opioids are effective against pain but can cause drowsiness, nausea, vomiting, constipation and dizziness. These medications can also cause psychological and physical dependence (addiction) when used over the long term. Consequently, doctors generally limit their use to several weeks.
Tramadol (Ultram), a strong opioid with a different mode of action, may be less addictive. A pill combining tramadol with acetaminophen (Ultracet) is also available. Like the other opioid drugs, tramadol may cause drowsiness, constipation, nausea and dizziness.
Injected pain relievers
Another approach to treating osteoarthritis is the use of corticosteroids and other drugs that are injected directly into painful joints (intra-articular injection). If acetaminophen or NSAIDs do not relieve your osteoarthritis symptoms sufficiently, you may be a candidate for intra-articular injections.
Often taken in oral form, corticosteroids are powerful anti-inflammatory hormones used by many people to treat rheumatoid arthritis and other inflammatory diseases. Corticosteroids can also relieve pain when injected into a joint. Intra-articular injections of corticosteroids have proven particularly effective for relieving painful osteoarthritis of the knee. Unfortunately, frequent corticosteroid injections increase the risk of cartilage damage. As a result, they should not be used more than two or three times a year.
Corticosteroid injections can’t reverse the underlying degenerative process in the joint, but they do relieve osteoarthritis pain for a few weeks or months. This temporary relief may allow you to begin physical therapy or reach a short-term goal, such as dancing at a wedding.
Hyaluronic acid injections (viscosupplementation)
The synovial fluid in your joints contains hyaluronic acid, a lubricating substance. Studies have shown that some individuals with osteoarthritis have a lower-than-normal concentration of this substance, especially in their knees. Some patients reported pain relief and improvement in knee function after a series of intra-articular knee injections of hyaluronic acid—also called viscosupplementation—administered over several weeks. As more data on the long-term effects of viscosupplementation have become available, the treatment has become less popular. And to date, no evidence indicates that it reverses or delays disease progression.
Many of the nonprescription creams, gels and ointments that are advertised for arthritis pain can provide some temporary pain relief. The three types of nonprescription topical analgesics are: Counter-irritants. Counter-irritant products contain compounds such as menthol, camphor, eucalyptus oil or turpentine oil that mask pain by producing a warm or cool sensation. A frequent side effect is reddening of the skin, which is harmless and temporary. Some of these products also contain salicylates or capsaicin—for example, BenGay, Flexall 454, Flexall Ultra Plus Gel and Icy Hot Stick.
Topical salicylates, such as Aspercreme and Sportscreme, work in the same way as aspirin—by inhibiting the release of prostaglandins, fatty acids that perform a variety of regulatory actions but also cause inflammation. Topical salicylates appear to relieve pain more effectively than a placebo, but no studies have compared these products with oral pain medications. Because some of the medication is absorbed into the body, people who are sensitive to aspirin or are taking drugs that might interact with aspirin may need to avoid these products.
Other topical preparations, such as Capzasin and Zostrix, contain capsaicin, the compound that gives hot peppers their “bite.” Capsaicin was once considered to be a questionable “alternative” remedy but now is an accepted part of conventional medicine.
Capsaicin works by reducing the amount of a neurotransmitter (chemical messenger) called substance P, which triggers transmission of pain impulses to the brain and can also provoke inflammation. Although topical capsaicin does not appear to cause any serious side effects, burning, stinging and redness occur in 40 to 70 percent of people who use the products. These side effects usually subside after several days of use.
Capsaicin products must be applied three to four times a day. It may take several weeks before you notice any benefits.
In general, topical treatments for joint pain cause few side effects, but some precautions apply. These medications are for external use only and should not come in contact with the eyes, nose, mouth or any open skin. You should wash your hands immediately after applying any of these products. Don’t use topical treatments more than three or four times a day, and discontinue them immediately if severe irritation develops. Many topical products come with warnings not to bandage or apply heat to a treated area. With some formulations, manufacturers recommend that you stop using the product and see a doctor if your symptoms do not improve after seven days. Also, don’t expect miracles or spend big bucks for “secret formulas.” If something sounds too good to be true, it probably is.
Although topical NSAIDs have been available for many years in Europe, they are relatively new in the United States. These preparations, which are available by prescription, have gained popularity because they effectively relieve pain while reducing the risk of systemic side effects associated with oral NSAIDs. The American College of Rheumatology now recommends topical NSAIDs over oral NSAIDs for knee osteoarthritis in patients over age 75, who are at higher risk of developing NSAID-related complications. To date, diclofenac gel (Voltaren) 1% has been approved by the FDA for osteoarthritis of the knee, hand and other joints amenable to topical treatment. Pennsaid, which also contains diclofenac, has been approved for knee osteoarthritis.