Technically, ‘arthritis’ includes over 100 different conditions from gout to tennis elbow. However, typically when we talk about arthritis we are talking about one of two different types: osteoarthritis or rheumatoid arthritis. Osteoarthritis is often related to aging or an injury. This is the type of arthritis that most often affects baby boomers and thus will be the type of arthritis we will focus on here.

Usually, non-drug therapies are not enough when treating osteoarthritis. Most people will have to use a combination of medication and non-drug therapies. Before beginning any drug therapy regimen for your osteoarthritis, it is important to discuss it with your doctor. There are many things to consider that can affect which therapy will be right for you.  

The American   College of Rheumatology ( ACR ) has given us guidelines on the treatment of osteoarthritis. In general, the main goal in treating osteoarthritis is to provide pain relief .

Acetaminophen (Tylenol®)

Acetaminophen (Tylenol®) is generally recommended first when treating mild to moderate osteoarthritis. It has many benefits. First of all, it is relatively cheap and is available over-the-counter. However, it does not help with the inflammation that can sometimes accompany osteoarthritis. The ACR recommends acetaminophen as the first choice to try for osteoarthritis pain for most people. It is up to you and your doctor to decide if you want to start with acetaminophen and work your way up or start with something that may help with any possible inflammation that may be present.  

Acetaminophen has been associated with liver damage so it should be used cautiously in people who have liver disease or a history of heavy alcohol intake. Care must also be taken not to exceed the maximum daily dose of 4 grams. Make sure you talk to you doctor before starting acetaminophen on a regular basis.   

NSAIDS (non-steroidal anti-inflammatory drugs)

NSAIDS are different from acetaminophen in that they can help with the inflammation that sometimes occurs with osteoarthritis. This class of drugs includes two subtypes: 1.) Traditional COX inhibitors generally referred to as ‘NSAIDS’ and 2.) COX -2 inhibitors.  NSAIDS and COX-2 inhibitors should be used cautiously as they have been linked with many side effects. For example, they can increase the risk of GI bleeds because they affect how well your blood clots. They may also increase your risk of kidney damage and possibly raise your blood pressure. Most recently, the use of COX -2 inhibitors has been shown to increase the risk of cardiac events like heart attack and stroke (more on this in a bit….).

Traditional NSAIDS  

These were the first anti-inflammation drugs on the market. Although there are many traditional NSAIDS, the studies seem to show that they are all about the same when it comes to effectiveness.  In other words, one is usually no better than the other as far as the studies go.^1,2 However, many people will find that certain NSAIDS work better for them than others. It is important to find out which one works the best for you.   

Table 2: Examples of Traditional NSAIDS

Many NSAIDS are available over-the-counter. However, for the reasons just mentioned above, it is a good idea to consult with your doctor before starting to take any NSAID on a regular basis. Just because they are over-the-counter does not mean they are harmless.

COX-2 Inhibitors  

COX-2 inhibitors are a newer type of anti-inflammatory drug.  These medications have an advantage vs. traditional NSAIDS in that they are less likely to cause GI problems. They also do not affect the way the blood clots like regular NSAIDS do. This means that these types of drugs may be safer to take before surgery.  

Table 5: Examples of COX-2 Inhibitors

As mentioned at the beginning of this section, COX -2 inhibitors have recently been associated with a higher risk of cardiac events like heart attack and stroke. The manufacturers of these drugs realized this and in 2004, Vioxx® was voluntarily pulled from the market. A short time later in 2005, Bextra® was also pulled from the market.  

Celecoxib (Celebrex®) still remains on the market. It was the first COX -2 inhibitor on the market. Earlier studies showed that celecoxib did not increase the risk of heart attack and stroke, however, these studies were not geared to detect such an outcome. There is newer preliminary evidence that suggests that celecoxib does increase the risk for cardiac events.  

Other Anti-inflammatory Drugs

There are a few drugs that are neither traditional NSAIDS or COX-2 inhibitors. Instead they act like one or the other depending on the dose. It was once thought that these drugs were not as hard on the stomach as traditional NSAIDS and that they did not increase the risk of heart attack and stroke the way COX-2 inhibitors did. This made these drugs great alternatives for controlling arthritis pain . However, all three of these drugs have been recently linked to a higher risk of heart attack and stroke. In particular, meloxicam has shown the most evidence of increasing these events. Further, studies show that meloxicam may not necessarily be easier on the stomach. Instead of pulling meloxicam off the market, the manufacturer chose to put a warning in the package insert that comes with the drug. In the case of etodolac and diclofenac , there have been studies suggesting these drugs put you at a higher risk of heart attack and stroke, but nothing conclusive as of yet. Etodolac and diclofenac are still considered to be easier on the stomach than traditional NSAIDS.  

Table 6: Examples of the ‘Other Anti-inflammatory Drugs’

If you are taking one of the drugs listed above that have been linked with a higher risk of heart attack or stroke, you may want to consult your doctor to see if there are other medications that may work for you. If you don’t want to take a COX-2 inhibitor because of the possible risk of cardiac events, but do not want to take a traditional NSAID because of the GI side effects, you may consider using a traditional NSAID in combination with a GI protective drug. An example of this could be taking ibuprofen (Motrin®) with omeprazole (Prilosec®). Examples of GI protective drugs are listed in the table below. Note that proton pump inhibitors (PPIs) have generally been shown to be more effective than H2 receptor antagonists in reducing the incidence of GI ulcers.

Table 7: Examples of GI protective Agents

Keep in mind that no studies have shown that COX-2 inhibitors work better than traditional NSAIDS. The choice to use one class or the other should be based on the side effects and how well they work for you. This is a decision that is best made together by you and your doctor.  

Table 8: Opioids  and Opioid Combinations Commonly Used to Treat Osteoarthritis

Potential side effects of opioids include confusion, dizziness, constipation, nausea and vomiting. Opioids can also cause respiratory depression, which makes breathing more difficult. Finally, they can also cause urinary retention (trouble urinating) as well.  

Topical remedies that contain capsaicin are usually the first topical choice for treating osteoarthritis pain. Capsaicin is  the ingredient found in chili peppers that gives them their hot flavor. When applied to the skin in the form of a cream or balm, capsaicin has been shown to decrease localized osteoarthritis pain. Capsaicin is found as the active ingredient in a variety of over-the-counter pain relief rubs and creams.  

Topical NSAIDS and aspirin-like rubs

There are a few topical NSAIDS available, however, they are typically available only by prescription. Many of these NSAID topicals, like ketoprofen gel, need to be specially prepared for you by your pharmacist.   

There are also a number of topical products available over-the-counter that contain aspirin -like substances called salicylates. These products not only relieve pain but may potentially help reduce joint inflammation as the product is absorbed into the skin. Examples of these preparations include Bengay®, Aspercreme® and Sportscreme®.  Remember, if you are allergic to aspirin or any other NSAIDS, do not use a topical NSAID or salicylate-containing product.  

Topicals That Distract You From Your Osteoarthritis Pain

There are a number of products available over-the-counter that produce a hot or cold sensation when applied to the skin. The sensation these products produce distracts you from the pain of osteoarthritis.  These products contain ingredients like oil of wintergreen, eucalyptus or menthol . Examples of these products include Icy Hot® and Joint Flex®.  

Topical Lidocaine  

Lidocaine is a local pain reliever that is sometimes found in topical pain relief remedies. It is also available in a prescription patch. Although not officially approved for osteoarthritis pain relief the patch has been shown to be effective in treating knee pain associated with osteoarthritis. Lidocaine works by producing a numbing sensation .    

Intra-articular injections

If you have tried other remedies and nothing seems to work, your doctor can inject corticosteroids or hyaluronic acid directly into the arthritic joint. Corticosteroids can help with pain and inflammation. Hyaluronic acid is thought to decrease inflammation, protect the cartilage and protect the nerve endings. The effects of intra-articular injections are fairly long-lasting so the injections can be done less often. Generally, your doctor will give the injection to you in his office. Intra-articular injections are generally used for knee osteoarthritis, however, there have been reports of using them on the hip as well.  

The Bottom Line

Osteoarthritis sufferers have more treatment options available today than ever before. Make sure you have a good relationship with your doctor and that she includes you as a part of the decision-making process. She should make decisions regarding your therapy using evidence-based medicine. Working closely with your doctor, pharmacist and the rest of your health care team should help increase your chances of success.

REFERENCES

1. Wilcox CM, Cryer B, Triadafilopoulos G. Patterns of use and public perception of over-the-counter pain relievers: focus on nonsteroidal antiinflammatory drugs. J Rheumatol. 2005;32:2218-2224. Abstract

    

2. Towheed T, Shea B, Wells G, Hochberg M. Analgesia and non-aspirin , non-steroidal anti-inflammatory drugs for osteoarthritis of the hip. Cochrane Database Syst Rev. 2000;(2):CD000517.