Pain medication for osteoarthritis

Treating Osteoarthritis of the Knee: Popular supplements don’t work

Osteoarthritis is the most common type of arthritis, affecting 1 in 10 Canadian adults (www.arthritis.ca). The knee is one of the most common and most symptomatically affected joints, causing knee pain in many people. They often try over-the-counter remedies to help the pain, and to avoid knee surgery. Amongst these treatments are the supplements glucosamine and chondroitin sulfate, which are very popular.

Because glucosamine and chondroitin are building blocks of cartilage, and because osteoarthritis is related to cartilage degradation, many believe that adding these building blocks to the diet of a person suffering from osteoarthritis will help rebuild cartilage and lessen pain. While on the surface this may seem logical, in reality these supplements do not provide effective pain relief. Here’s why:

These popular supplements don’t work.

Many studies have shown that glucosamine and chondroitin sulfate do not help to relieve pain from arthritic knees. People who take the supplements often report less pain or swelling of their joints. But people get similar results if they take a placebo—a “sugar pill” with no active ingredients. Pain relieving drugs, such as acetaminophen (Tylenol and generic) and ibuprofen (Advil, Motrin IB and generic), help a lot more.

The supplements can be dangerous.

Glucosamine and chondroitin are not harmful by themselves, but they can interact with other medicines. For example, the supplements can increase the effect of warfarin (Coumadin and generics) on blood clotting. This increases the risk of bruising and serious bleeding. Problems with warfarin frequently lead to emergency room visits.

You aren’t always getting what you think.

To make matters worse, often the labels on the bottles are misleading. In 2013, Consumer Reports tested 16 joint pain supplements and found that seven had less chondroitin than the label listed.

Other approaches often work better.

There are more effective ways to relieve arthritic knee pain:

  • Physical therapy
  • Losing weight
  • Acetaminophen (Tylenol and generic)
  • Ibuprofen (Advil, Motrin IB and generic)
  • Naproxen sodium (Aleve and generic)
  • Other anti-inflammatory medications

If these don’t help, you can talk to your doctor about treatments such as injections or surgery.

Steps to help ease the pain of osteoarthritis of the knee:

Lose excess weight. Losing a pound of excess weight can take about four pounds of pressure off your knees when walking.

Physical activity. To build support of the knees, do strength training, especially of the quad muscles on the front of the thigh. Aerobic exercise builds strength and can reduce pain. Stretching can help prevent stiffness. Ask a local YMCA or gym about exercise programs for people with arthritis.

Mechanical aids. A cane, crutch, or walker can take a load off painful knees.

Heat and cold. A heating pad can ease ongoing stiffness and soreness in joints. For acute pain and swelling, switch to ice packs.

Massage. Deep-tissue massage got high marks in a 2010 survey of Consumer Reports online readers. Half of them said that it “helped a lot” with their osteoarthritis.

Use drugs carefully.

  • Ibuprofen (Advil, Motrin IB and generics) and naproxen (Aleve and generics) can ease pain and inflammation. But they may cause stomach bleeding and high blood pressure, if taken over a longer time. Try to use them only for short periods.
  • Acetaminophen (Tylenol and generic) can also help reduce pain, but high doses can damage your liver. Make sure you take less than 4,000 mg a day.

One of the benefits of modern medicine is the large selection of pain relievers available. The challenge is finding the right one at the right dose to reduce your osteoarthritis (OA) pain. With so many available, which is the most effective?

Researchers analyzed 74 studies involving a total of 58,556 people with OA pain in their knees and hips. The studies looked at pain relievers available in the United States, including acetaminophen (Tylenol) and the nonsteroidal anti-inflammatory drugs (NSAIDs) celecoxib (Celebrex), diclofenac (Voltaren), ibuprofen (Advil, Motrin) and naproxen (Aleve). It also covered medications not available in the U.S., such as etoricoxib, lumiracoxib and rofecoxib.

The results, published online in The Lancet in March 2016, suggest that while the NSAIDs studied reduced OA pain better than taking nothing, diclofenac, at the maximum approved daily dose of 150 mg per day, may be the most effective. The researchers also found that, in general, the higher the dose, the better the drugs worked.

But there are caveats, says Marcus M. Reidenberg, MD, professor emeritus of pharmacology at Weill Cornell College of Medicine in New York: “The average follow-up was 12 weeks. Osteoarthritis is a lifetime disease. Sometimes people use a drug for a while and then it stops working, so they switch to another,” says Dr. Reidenberg, who was not involved with the study. Plus, the age of the study participants was, on average, 58 to 71. Also using oral NSAIDs for a long time can result in stomach problems like bleeding, ulcer, and stomach upset, as well as high blood pressure and kidney problems. Other harmful side effects that increase with age include a higher risk for cardiovascular and gastrointestinal events.

“The bottom line is that it may come down to cost and medical history, including your individual risk of side effects,” Dr. Reidenberg says.

A chronic condition, such as OA can be challenging to treat. Experts believe that a multidisciplinary team of health care providers using different pain management approaches is the most effective strategy rather than relying on a particular medication.

September is Pain Awareness Month! Visit our Breaking the Pain Chain Toolkit, sponsored by Biofreeze, for practical tips on how to create and enact a personalized pain management plan to help you manage your pain and preserve your quality of life.

Author: TERRI D’ARRIGO

Related Resources:

  • Developing Your Pain Management Plan
  • Arthritis Pain Management
  • Pain Treatment for Osteoarthritis Targets Nerves
  • Understanding Over-the-Counter Pain Medication Infographic

Medical Treatment for Osteoarthritis of the Hip

If osteoarthritis of the hip causes aching pain and limits your ability to move without discomfort, your doctor may recommend an over-the-counter pain relief medication. Many doctors recommend acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin, ibuprofen, and naproxen. These medications are taken by mouth and are available at drugstores.

Acetaminophen blocks pain signals that travel from the site of an inflamed joint to the brain, and NSAIDs relieve pain and swelling that occurs when the body’s immune system responds to joint damage caused by arthritis.

Many people find that over-the-counter pain relief medications alleviate aching and stiffness in arthritic joints, making movement easier. Your doctor can explain the risks and recommend a safe regimen for you based on your symptoms, age, and other medical conditions that could affect or interact with these medications.

While acetaminophen is safe in moderate doses, it has been linked to liver difficulty with long-term use. Anti-inflammatory medications may also cause side effects such as high blood pressure, headaches, upset stomach, and kidney disease.

If over-the-counter medications don’t work to relieve pain and stiffness from osteoarthritis within a few weeks, NYU Langone doctors may prescribe a stronger medication.

Osteoarthritis (OA) is a disease of the bone joints that can cause severe pain and swelling. The cartilage around the ends of your bone joints wears away over years of use and leaves the bones rubbing against each other. This can make them inflamed and painful.

Your doctor may ask you to make lifestyle changes like exercise, losing weight, and changing your eating habits. In addition to those options, there are several medications that may help you. Some are available over the counter while others need a prescription. They can be pills, creams, lotions, or injections.

Here are some of them and how they work:

Analgesics: These are medicines that relieve pain but don’t reduce inflammation. They work to change how your body responds to pain. Popular options include acetaminophen, tramadol, and prescription opioids containing oxycodone or hydrocodone. The opioids can be addictive.

Your maximum daily dosage of acetaminophen should be 4,000 milligrams (mg), if you don’t have any liver disease. Too much can cause liver damage or even death.

Nonsteroidal anti-inflammatory drugs (NSAIDs): These drugs reduce inflammation as well as ease pain. These are some of the most popular medications given for arthritis. NSAIDs include aspirin, ibuprofen, naproxen, and celecoxib. They are usually taken in pill form but may cause stomach upset or bleeding. Make sure to follow the maximum daily dosage limits for each medication. Some are also available as creams to rub on your joints (for instance, Aspercreme). Some NSAIDs may increase your risk of heart disease or stroke. It’s actually recommended that you don’t use NSAIDs if you have an ongoing health condition such as heart disease, liver disease, or kidney disease. NSAIDs are non-narcotic and non-addictive.

Whether you should take opioids or NSAIDs is up to you and your doctor. One study showed that opioids and NSAIDS were equally effective for reducing the pain of OA of the knee — about 30% pain reduction for each.

Counterirritants: These are creams and ointments containing ingredients like menthol or capsaicin, the ingredient that makes hot peppers burn. Rubbing these on your painful joints may stop the pain signals from the joint to the brain.

Osteoarthritis: prescription medicines

If you suffer from osteoarthritis, then medicines to provide pain relief and reduce inflammation will likely form part of your treatment plan. Much of osteoarthritis treatment and prevention is physical or biomechanical — aimed at reducing stress on joints or improving strength and stopping progression. This is often achieved by losing weight, if you are overweight, and with strength and flexibility exercises. However, pain relief is no less important, and this is where medicines can help people with osteoarthritis.

Paracetamol

Paracetamol is often the first medicine tried for the pain of osteoarthritis, however, recent guidelines do not recommend it as a first option, and show only low-level pain relief for osteoarthritis – and in knee osteoarthritis only the same level of pain relief as dummy treatment (placebo). A 2016 analysis of paracetamol to treat knee and hip osteoarthritis did not recommend it and found it to be clinically ineffective.

Although paracetamol is available without a prescription, this does not mean it is without side effects and concerns are increasing around its safety in high doses when used regularly for pain relief, and when it is taken along with NSAIDs (non-steroidal anti-inflammatory drugs, such as ibuprofen).

You should not take more than 8 tablets (4 g) per 24 hours without consulting your doctor, as liver damage may occur in amounts greater than this.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (known for short as NSAIDs) are increasingly replacing paracetamol as the first recommendation for medicines to help with osteoarthritis pain and inflammation symptoms. Many people with chronic arthritis are helped by taking one of the NSAIDs.

There are 2 types of NSAIDs: non-selective and selective (also known as coxibs or cox-2 inhibitors). Some NSAIDs such as ibuprofen (Nurofen) or diclofenac (Voltaren) can be purchased over the counter from a pharmacy, and others are prescription only, such as naproxen (e.g. Naprosyn).

Selective NSAIDs (coxibs) are only available with a prescription

As their name implies, NSAIDs reduce inflammation of the joints, without using steroids. Taking these medicines can reduce the pain of arthritis, reduce joint stiffness and improve mobility. However, NSAIDs do not cure arthritis or have a long-term effect after you stop taking them.

Non-selective NSAIDs

There doesn’t seem to be any major difference between NSAIDs in terms of their effectiveness, but some people get more relief from one NSAID than another, so you may need to try a couple of different NSAIDs to find one that works for you. Your doctor will be able to advise you on whether NSAIDs are suitable for you and which one to try.

Side-effects of NSAIDs

Unfortunately, non-selective NSAIDs have the potential to cause gastrointestinal side-effects such as stomach ulcers and bleeding, which limits their use for those people susceptible to stomach problems. NSAIDs should be taken with food to lessen any risks of side effects.

All NSAIDs should also be used at the lowest possible dose that controls symptoms for the shortest possible time.

If you develop any symptoms such as bloody or black stools or vomit blood, or have severe stomach pains you should get immediate medical attention.

Taking NSAIDs may also put people at increased risk of heart attack and stroke, especially people already at higher risk. NSAIDs can also make heart failure and kidney failure worse. This is true for both types of NSAIDs – selective and non-selective.

If you take ‘blood-thinning’ anti-coagulant drugs, such as warfarin, you should check with your doctor before taking NSAIDs, as the drugs in combination may increase your risk of bleeding.

Selective NSAIDs (Coxibs)

Selective NSAIDs, also called COX-2 specific inhibitors or coxibs, are a more recent class of medicine which appears to be just as effective in relieving pain and inflammation as the older NSAIDs, but with fewer side-effects.

Celecoxib (including brand names Celebrex, Celecoxib Sandoz), etoricoxib (brand name Arcoxia) and meloxicam (Mobic, Movalis) are the coxibs available in Australia. They are available only with a prescription.

Side-effects of coxibs

Coxibs are believed to cause fewer gastrointestinal side effects and may be suitable for some people who cannot take the older, non-selective NSAIDs.

However, all NSAIDs, including these newer selective types (coxibs), may increase the risk of heart attack and stroke. As mentioned above this risk appears to be higher in people who are already at high risk of heart attack or stroke (e.g. those with a history of heart attack or stroke, smokers, people who are overweight, those with high cholesterol, high blood pressure, or diabetes). NSAIDS can also increase blood pressure and make heart failure and kidney failure worse.

You can discuss the risks and benefits of treatment with NSAIDs with your doctor, who will be able to tell you whether or not they are suitable for you.

Topical NSAIDs

Topical NSAIDs (which are rubbed into the skin) are available as creams or gels and can help ease pain around joints, such as in osteoarthritis of the knee or hand. Their effect is limited to the area they are applied to.

Topical NSAIDs include piroxicam (Feldene Gel), ibuprofen (Nurofen Gel), and diclofenac (Voltaren Emulgel, Dencorub Anti-inflammatory Gel). They are available over-the-counter from pharmacies.

Even though topical NSAIDs are applied to the skin, they may still cause side-effects, however, because the amount used is usually lower, side-effects are reduced compared with oral NSAIDs. Some people experience the side-effect of a skin rash. If you get a skin rash while using a topical NSAID, stop using it and see your doctor.

Another potential side-effect of some topical NSAIDs is photosensitivity – when your skin becomes sensitive to light and you experience a rash or sunburn when you wouldn’t normally expect to.

Other analgesics (painkillers)

Codeine combinations

Simple analgesics (painkillers) such as NSAIDs or paracetamol should be tried before combination analgesics such as paracetamol plus codeine or NSAID plus codeine. Osteoarthritis is more common in elderly people than younger people, and it is normally recommended that the elderly avoid products containing codeine as it affects the central nervous system (CNS) and elderly people may be more susceptible to CNS effects such as drowsiness and sedation. In addition, medicines such as codeine can cause constipation.

Tramadol

Tramadol (e.g. Tramal and other brands) is a prescription painkilling medicine that is classified as an opioid (morphine-like) agent, but that also has some additional actions. It may be helpful in arthritis pain not relieved by NSAIDs (non-steroidal anti-inflammatory drugs), however tramadol may cause side-effects, such as sedation and nausea (feeling sick) that limit its use. Tramadol may also be addictive in some cases.

Tapentadol

Tapentadol (brand name Palexia) is another opioid with similar actions to tramadol. It is a strong pain reliever and like other opioid pain relievers may be addictive. Tapentadol has not been used in Australia for as long as tramadol. It is currently only available for ongoing severe disabling pain that isn’t relieved by non-opioid medicines. Side effects include drowsiness and dizziness and constipation.

Corticosteroid injections

Corticosteroids are a type of steroid naturally made by the adrenal glands. They work by acting against inflammation and in higher doses suppress the immune system. Corticosteroids can be taken as tablets or as injections into the joint, which is more common in osteoarthritis. Corticosteroid injections can provide short-term pain relief from arthritis. Your doctor will advise whether this is recommended for you.

Frequent injections of corticosteroids may lead to damage to joint structures, so this treatment is usually limited to 2-3 times per year. You may be advised to avoid using the joint too much for 24-48 hours after the injection to ensure the beneficial effects last as long as possible.

Hyaluronan injections

Hyaluronan (hyaluronic acid) is a natural component of the synovial fluid in a joint and plays a critical role in normal joint functions, such as lubrication and keeping down inflammation. In a joint with osteoarthritis, the hyaluronan is affected and can’t carry out these functions so well. Injecting hyaluronan into a joint to supplement the natural hyaluronic acid theoretically helps with lubrication of the joint and shock absorption, however, results concerning its effectiveness are inconsistent.

Hylan (e.g. brand name Synvisc) is a hyaluronan-based product available for the treatment of pain associated with osteoarthritis of the knee. It is given as a course of 3 injections over 3 weeks.

Durolane is a brand of hyaluronic acid used for injection to treat osteoarthritis of the knee. One injection is given per treatment course.

Sodium hyaluronate (e.g. Fermathron) is a similar product also available for osteoarthritis of the knee joint. It is given by injection into the affected joint once weekly for no more than 5 weeks.

These products are not currently subsidised on the PBS so the treatment may be expensive. Trials have shown inconsistent evidence of benefit.

Side effects of these injections include short-lived pain and swelling around the injection site.

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Last Reviewed: 05/10/2016

NSAIDs Over Acetaminophen for Arthritis Pain

Study finds that the NSAID diclofenac may be a better option for arthritis pain than Tylenol.

By Reviewed By Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE

What medication should you reach for when you are experiencing aches and pains in your hands or knees?

Many people wonder what is the best pain medication for arthritis pain.When it comes to the pain and stiffness of osteoarthritis, researchers of a new study are now recommending you reach for a nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin) or diclofenac, rather than acetaminophen (Tylenol).

“Regardless of dose, the prescription drug diclofenac is the most effective drug among painkillers in terms of improving pain and function in osteoarthritis,” said Sven Trelle, MD, co-director of clinical trials at the University of Bern, Switzerland, and lead researcher of the new study published in The Lancet.

Osteoarthritis is the most common form of arthritis, affecting approximately 27 million Americans aged 25 and older, primarily those over the age of 65. It causes pain, swelling, and reduced motion in any joint, but usually it affects hands, knees, hips or spine. It can impair physical activity, and that increases the risk of obesity, heart disease, diabetes and general poor health, the study authors said.

Acetaminophen and NSAIDs are considered a first-line treatment for relieving mild-to-moderate pain among patients with osteoarthritis, though Dr. Trelle and colleagues note in an article in MNT that acetaminophen is more widely used in the long term because it poses fewer side effects than NSAIDs.

Although the study found diclofenac to be the best choice, all of the medications come with side effects and there is a lot of inter-patient variability. “If you are thinking of using a painkiller for osteoarthritis, you should consider diclofenac,” Dr. Trelle said, but also keep in mind that like most NSAIDs the drug can increase the chance of a heart attack or stroke, either of which can lead to death, according to the Food and Drug Administration.

Tylenol manufacturer McNeil Consumer Healthcare took issue with the new study, according to a report in MedLinePlus. “We disagree with the authors’ interpretation of this meta-analysis and believe acetaminophen remains an important pain relief option for millions of consumers, particularly those with certain conditions for which NSAIDs may not be appropriate — including cardiovascular disease, gastrointestinal bleeding, and renal disease,” the company said in a prepared statement.

“The safety and efficacy profile of acetaminophen is supported by more than 150 studies over the past 50 years,” the company added.

Current Study

OTC vs prescription pain medications—which is best?The current research was a restrospective review of 74 trials published between 1980 and 2015. These trials included more than 58,000 patients. The studies compared how well various doses of acetaminophen and 7 different NSAIDs relieved arthritis pain.

The researchers found that acetaminophen was only slightly better than placebo. But they added that taken by itself, acetaminophen has no role in treating osteoarthritis, regardless of dose. .

Not surprising, the maximum daily dose of diclofenac (150 mg daily) was the most effective treatment for pain and disability, the new study showed. The researchers also found diclofenac was better than the maximum doses of NSAIDs, including ibuprofen, naproxen (Aleve) and celecoxib (Celebrex).

According to Mary Lynn McPherson, PharmD, acetaminophen is commonly used to reduce a fever and to treat both acute pain (such as headache, toothache, sprains or muscle strains) and chronic pain (back pain).

But acetaminophen does carry risks. Based on current research, doses up to 3,000 mg per day, or 4,000 mg per day under a doctor’s supervision, are considered safe. However, taking more than 4,000 mg per day may cause liver damage, either as one large dose, or excessive doses over weeks or months, noted Dr. McPherson. In addition, acetaminophen overdose is a leading cause of acute liver failure.

For these reasons, some doctors prefer short-term use of NSAIDs, which targets inflammation, to acetaminophen for chronic pain conditions like osteoarthritis.

Updated on: 03/22/16 View Sources

Trelle S, et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis, Sven Trelle et al., The Lancet. 17 March 2016 .

Continue Reading: Exercise to Manage Knee Osteoarthritis

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