Several effective medications are available to relieve pain related to osteoarthritis. Oral medications are used more frequently, but research that links some with an increased risk of heart disease has made doctors less inclined to prescribe 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 painkillers can make you feel better, they can not cure your osteoarthritis. Researchers, however, are working on identifying medications that can reverse or prevent worsening of the condition.
Taking an oral analgesic is sometimes the first step in the medical treatment of osteoarthritis.
The most commonly used analgesics are acetaminophen (Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs). What 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 possible side effects is usually tried first. If this drug does not relieve pain properly, other pain medications may be added or replaced.
It is important to note that the American Heart Association has issued guidelines recommending that physicians do not prescribe NSAIDs or COX-2 inhibitors (a new generation of NSAIDs) to patients at risk for heart attack, including those with coronary disease or Established risk Factors such as high blood pressure or high cholesterol until you have tried other methods to relieve a patient’s pain.
This over-the-counter medication is the initial drug of choice for osteoarthritis because it is as effective as most NSAIDs and is less likely to cause side effects, such as stomach irritation. It is also cheap. Because inflammation only plays a minor role in osteoarthritis, the anti-inflammatory effect of an NSAID is usually not necessary.
The maximum recommended 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 amount.
Acetaminophen can be harmful to people who drink large amounts of alcohol. To help prevent liver damage, you should avoid consuming alcohol while taking this medicine. Acetaminophen can also be dangerous if you are taking the anticoagulant warfarin (Coumadin). Although paracetamol appears to be associated with a slightly lower risk of heart disease than NSAIDs, if you use it regularly, you should consult your doctor periodically to check for side effects.
If acetaminophen does not control your pain, NSAIDs are the next option. Aspirin, the original NSAID, is effective and inexpensive and can reduce the risk of heart disease. Other NSAID options include ibuprofen (Advil, Motrin), naproxen (Aleve), and ketoprofen.
If you need a 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 not usually a major problem in osteoarthritis, NSAIDs are mainly used as analgesics in this circumstance.
How well the symptoms of osteoarthritis respond to a specific NSAID varies greatly from person to person. As a result, finding the right medication depends largely on trial and error. It can take at least two weeks of treatment to find out if the drug is effective.
Regular use of NSAIDs can cause stomach irritation, bleeding, and ulceration because medications interfere with the formation of protective mucus that normally lines the stomach. In fact, some degree of gastrointestinal bleeding occurs in more than 50 percent of NSAID users.
If you develop gastrointestinal upset or blood in the stool 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 that dissolves in the intestine instead of the stomach) or a traditional NSAID in combination with a medicine 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 60 years of age, 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 monitor it carefully while you are taking NSAIDs or you should avoid them completely .
Many doctors now recommend topical NSAIDs for people at increased risk of adverse effects from oral NSAIDs. Regular monitoring can detect liver and kidney problems in their 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, as it may increase the effects of these medications. NSAIDs, especially aspirin, can also worsen asthma.
Developed in the 1990s, COX-2 inhibitors were a new type of NSAID at the time it prevented 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.
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 doctors reserve Celebrex for people who 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 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.
Another approach to treating osteoarthritis is the use of corticosteroids and other drugs that are injected directly into the painful joints (intra-articular injection). If acetaminophen or NSAIDs do not sufficiently alleviate the symptoms of osteoarthritis, it may be a candidate for intra-articular 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 joint. Intra-articular injections of corticosteroids have been shown to be particularly effective in relieving painful osteoarthritis of the knee. Unfortunately, frequent injections 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 can not reverse the underlying degenerative process at the joint, but alleviate osteoarthritis pain for a few weeks or months. This temporary relief can allow you 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, a lubricating substance. Studies have shown that some people 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 injections of the hyaluronic acid knee-also called viscosupplementation-administered for several weeks. As more data on the long-term effects of viscosupplementation have become available, treatment has become less popular. To date, no evidence indicates that it slows or delays the progression of the disease.
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 pain 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 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 placebo, but no study has compared these products with oral analgesics. Because some of the medication is absorbed into the body, people who are sensitive to aspirin or are taking medications that could interact with aspirin may be necessary 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 a questionable “alternative” remedy, but is now an accepted part of conventional medicine.
Capsaicin works by reducing the amount of a neurotransmitter (chemical messenger) called substance P, which triggers the transmission of pain impulses to the brain and can also trigger 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 go away after several days of use.
Capsaicin products 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 any of these products. 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 apply heat to a treated area. With some formulations, 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 probably is.
Although topical NSAIDs have been available for many years in Europe, they are relatively new in the United States. These prescription-only preparations 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 for oral NSAIDs for osteoarthritis of the knee in patients over 75 years of age who are at increased 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 susceptible to topical treatment. Pennsaid, which also contains diclofenac, has been approved for osteoarthritis of the knee.