What You Need to Know About Arthritis Medications

Several effective medications are available to relieve pain caused by osteoarthritis. Use of osteoarthritis medications is widespread even though the research links some drugs to an increased risk of heart disease and some doctors are less inclined to prescribe it. Some research also finds that injections into the affected joint also help significantly reduce pain.

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Although painkillers can make you feel better, they do not cure your osteoarthritis. Researchers, however, are working on medications that can reverse or prevent worsening of the condition.

Oral analgesics

Oral analgesic is sometimes the first step in the treatment of osteoarthritis.
The most commonly used analgesics are acetaminophen (Tylenol) and other non-steroidal anti-inflammatory drugs (NSAIDs). What medication your doctor will recommend to you depends on the intensity of your pain and risk of side effects. The doctor prescribes the drug with the fewest possible side effects first. If the medicine does not relieve pain, other pain medications may be added.

It is important to note that the American Heart Association has issued recommendations for physicians not to prescribe NSAIDs or COX-2 inhibitors (a new generation of NSAIDs) to patients at risk for heart attack, including patients with coronary disease, high blood pressure or high cholesterol.

Acetaminophen (Tylenol)
This over-the-counter medication is the drug of choice for osteoarthritis treatment because it is as effective as most NSAIDs. It is less likely to cause side effects such as stomach irritation. It is also cheap. Inflammation plays a minor role in osteoarthritis, the anti-inflammatory effect of an NSAID is usually not expected.

The maximum recommended a daily dose of acetaminophen is 4,000 milligrams (mg), usually 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 is easy to consume too much if you are not careful. Acetaminophen can cause liver damage if taken at doses higher than the recommended one.

Acetaminophen can be harmful to people who drink alcohol. To prevent liver damage, you should not drink alcohol while taking medicine. Acetaminophen can also be dangerous if you take the anticoagulant Warfarin (Coumadin). Although paracetamol is less associated with a risk of heart disease than other NSAIDs, you should consult your doctor and check for side effects.

Traditional NSAIDs

If acetaminophen does not manage your pain, NSAIDs are your next option. Aspirin, the original NSAID, is efficient and inexpensive and can reduce the risk of heart disease. Other NSAID options include ibuprofen (Advil, Motrin), naproxen (Aleve), and ketoprofen.

If you need an NSAID other than aspirin, the American Heart Association recommends naproxen. If necessary, your doctor may prescribe a stronger NSAID such as diclofenac (Voltaren) or nabumetone.

Because inflammation is not usually a significant problem in osteoarthritis, NSAIDs are used as analgesics.

How the pain symptoms of osteoarthritis respond to a specific NSAID varies. Often finding the right medication is done by trial and error. It can take at least two weeks to find out if the drug is effective.

Regular use of NSAIDs can cause upset stomach, bleeding, and ulceration because medications interfere with the formation of a protective layer that lines the stomach. In fact, more than 50% patients who use NSAIDs have some gastrointestinal bleedings. If you develop gastrointestinal problems such as upset stomach or blood in the stool while taking an NSAID, call your doctor.

To reduce the risk of gastrointestinal problems, take a traditional NSAID that is less likely to affect your stomach (for example, enteric-coated aspirin that dissolves in the intestine instead of the stomach) or a regular NSAID in combination with a medicine that protects your stomach. The Food and Drug Administration (FDA) recommends Misoprostol (Cytotec). Consult your doctor.

Do not take NSAIDs if you are over 60 years, take corticosteroids, have a history of stomach ulcers or adverse reactions to NSAIDs, or have heart disease, diabetes or liver or kidney problems.

Many doctors recommend topical NSAIDs for people with increased risk of adverse effects from oral NSAIDs. Regular monitoring can detect liver and kidney problems at early stages before they become serious. Your doctor can also monitor your blood pressure, blood counts, and potassium levels during long-term NSAID treatment. If you take oral medications for diabetes or warfarin, be careful when using an NSAID. It may increase the effects of these medicines. NSAIDs, especially aspirin, can also worsen asthma.

COX-2 Inhibitors

COX-2 inhibitors were developed in the 1990s as a new type of NSAID. However, 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 but it is still available.

Medication has a 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 doctors reserve Celebrex for people who do not benefit or who have adverse effects to other painkillers and are at low risk for heart attacks and strokes. Typically, in such cases, the lowest effective dose is used for the shortest possible time. The most recent evidence shows that almost all NSAIDs pose cardiovascular risks, and their labels also warn of the potential for this adverse effect.

Injected Analgesics

Another approach to treating osteoarthritis is to inject corticosteroids and other drugs directly into the painful joints (intra-articular injection). If acetaminophen or other NSAIDs do not sufficiently alleviate the symptoms of osteoarthritis, you may be a candidate for intra-articular injections.

Corticosteroid Injections

Often taken orally, corticosteroids are potent anti-inflammatory hormones used by many people to treat rheumatoid arthritis and other inflammatory diseases. Corticosteroids can also relieve pain when injected into a damaged joint. Intra-articular injections of corticosteroids have been found useful in reducing painful knee osteoarthritis. Unfortunately, frequent doses of corticosteroids increase the risk of cartilage damage. As a result, they should not be used more than two or three times a year.

Corticosteroid injections cannot reverse the underlying degenerative process of the joint but can alleviate osteoarthritis pain for a few weeks or months. This temporary relief can allow the patient to begin physical therapy or achieve a short-term goal, such as dancing at a wedding.

Injections of Hyaluronic Acid (viscosupplementation)

The synovial fluid in your joints contains hyaluronic acid as a lubricating substance. Studies have shown that some people with osteoarthritis have a lower than average concentration of hyaluronic acid, especially in their knees. Some patients report pain relief and improvement in knee function after a series of intra-articular injections of the hyaluronic acid into the knee. It is also called viscosupplementation. As more data on the long-term effects of viscosupplementation have become available, treatment has become more popular. However, there is no evidence indicating that it slows or delays the progression of the disease.

Topical analgesics

Many of the over-the-counter creams, gels and ointments that are advertised for arthritis pain can provide some temporary relief from pain. The three types of over-the-counter pain relievers are contra-irritants. Anti-irritant products contain compounds such as menthol, camphor, eucalyptus oil or turpentine oil that mask illness resulting in a feeling of heat or cold. A common 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 like 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 placebo, but there is no study comparing the salicylates with oral analgesics. People who are sensitive to aspirin or are taking medications that could interact with aspirin should avoid salicylates.

Other topical preparations, such as Capzasin and Zostrix, contain capsaicin, the compound that gives hot peppers their “bite”. Capsaicin was once considered a questionable “alternative” remedy, but now is recognized as traditional medicine.

Capsaicin works by reducing the number of neurotransmitters (chemical messengers) called substance P which trigger the transmission of pain impulses to the brain and can also cause inflammation. Although topical capsaicin does not appear to cause any severe side effects, burning, stinging and redness occur in 40 to 70 percent of patients. The side effects usually go away after several days of use.

Capsaicin should be applied three to four times a day. It may take several weeks before you notice any benefit.

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 it. Do not 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 heat to a treated area. The manufacturers recommend that you stop using the product and consult a doctor if your symptoms do not improve after seven days. Also, do not expect miracles or spend a lot of money on “secret formulas.” If something sounds too good to be true, it is probably not.

Topical NSAIDs
Although topical NSAIDs have been available for many years in Europe, they are relatively new in the United States. These prescription-only medications have gained popularity because they effectively relieve pain while reducing the risk of side effects associated with oral NSAIDs. The American College of Rheumatology now recommends changing oral NSAIDs for topical NSAIDs for knee osteoarthritis in patients over 75 years of age who are at increased risk of developing NSAID-related complications. The FDA approved Diclofenac gel (Voltaren) and Pennsaid (diclofenac) for knee osteoarthritis.