A guide to different prescribed osteoarthritis drugs according to the patient’s level of pain
Osteoarthritis (OA) is a degenerative joint disease that occurs when the protective cartilage on the ends of bones wears down over time, leading to irritation, pain, swelling and loss of motion. OA often gradually worsens over time, and there is no cure for it. Pain medications — ranging from topical creams to injections — can offer symptomatic relief but cause side effects; so delaying or minimizing drug use is of benefit to OA sufferers. (See Food as Medicine: Osteoarthritis for suggestions on how weight loss, diet and supplements can help.)
If drugs are needed as part of a treatment plan, doctors will prescribe drugs according to an OA patient’s level of pain. (For a full list of medications, their side effects and potential drug interactions, see the Arthritis Today Drug Guide, compiled in conjunction with the Arthritis Foundation.)
For Mild Pain
Topical analgesic creams, salves and gels are a first line of defense. They are applied directly to the skin and can help relieve mild joint and muscle aches. Brand names include Aspercreme, Bengay, Capzasin-P, Flexall and Voltaren Gel.
Side effects: Little (if any) of a topical product is absorbed into the bloodstream, but side effects may include skin irritation or, in rare cases, allergic reactions such as wheezing, hives or a swelling of the lips or tongue.
For Mild to Moderate Pain
Over-the-counter oral analgesics such as acetaminophen (Tylenol) provide temporary pain relief. Nonsteroidal anti-inflammatory drugs (NSAIDs) treat pain, swelling and stiffness. They interfere with the body’s production of prostaglandins, hormone-like chemicals that contribute to inflammation. Common NSAIDs include aspirin, ibuprofen (Advil), naproxen (Aleve) and prescription-strength celecoxib (Celebrex).
Side effects: Analgesics like acetaminophen are generally safe when taken as directed. But if used with other products that contain acetaminophen, in too high a dose, they can cause liver failure or even death. (See Double Trouble With Acetaminophen.) In addition, studies have shown that NSAIDs can cause or exacerbate psoriasis, an immune disorder.
NSAIDs are not great for long-term pain management. NSAIDs such as aspirin, ibuprofen and naproxen have been linked to an increase in gastrointestinal bleeding and stomach ulcers if taken in excess. COX-2 inhibitors — a newer class of NSAIDs that includes Celebrex — may increase the risk of heart attack, stroke and other related conditions, particularly in those who have, or are at risk for, heart disease. For this reason, the FDA has issued a black box warning for Celebrex. (To read more about the long-term side effects of NSAIDs, see Pain Relievers a Headache for Cardiologists.)
5 Questions to Ask Your Doctor
Before taking OA medications, ask your health provider:
- Do I need this particular drug? Are there any lifestyle or dietary changes I might try first — or in conjunction with the drug?
- What is the drug’s safety record, and how can I learn more about it? What are the short- and long-term side effects?
- I am taking medications for other conditions (mention both OTC and prescription drugs). Will it be safe for me to take the OA drug you’re prescribing?
- Are there complementary and alternative treatments I might consider?
- What can I do to prevent my condition from getting worse?
Sufferers with knee OA who do not respond to NSAIDs or have adverse side effects from these drugs may be given hyaluronic acid injections. Hyaluronic acid occurs naturally in joint fluid, acting as a shock absorber and lubricant. The acid appears to break down in those with OA. Hyaluronic injections — given under the brand names Synvisc or Hyalgan — help to lubricate joints and lessen pain and inflammation. Sufferers often receive a series of 3 to 5 injections, with results lasting up to 6 months.
Side effects: Some pain, swelling, heat, redness and/or fluid buildup around the knee may be experienced. In rare cases, sufferers may have an allergic reaction such as hives, difficulty breathing, and swelling of the lips or tongue.
For Moderate to Severe Pain
Corticosteroid injections are prescribed for OA sufferers who need quick relief from severe inflammation. The American College of Rheumatology recommends they be given to patients with moderate to severe knee pain and inflammation who do not respond to acetaminophen. The shots are injected into or around the inflamed joints; effects may last up to several weeks.
Side effects: Side effects may include pain at the injection site (called a cortisone “flare” reaction), infection, damage to soft tissue, and increased blood sugar levels (diabetics should be carefully monitored after receiving these injections). To reduce the risk of side effects, doctors recommend that OA sufferers receive no more than 3 to 4 injections in the same joint each year.
For Severe Pain
Opioids are sometimes prescribed for chronic OA-related joint pain or to ease acute pain after joint surgery. Such drugs include morphine, methadone and oxycodone (Schedule II narcotics) and hydrocodone (a Schedule III drug). Because these medications have the potential for abuse and psychological and physical dependence, they are best used on a short-term basis.
Side effects: Side effects can range from dry mouth, constipation and headache to dizziness, drowsiness and shortness of breath. With long-term use, opioids can lead to physical dependence and withdrawal symptoms, such as agitation, muscle aches, insomnia, nausea and vomiting. As with all other OA medications, opioids may help to relieve pain and other symptoms, but they don’t reverse the arthritic process or help rebuild cartilage. In the event that an OA sufferer gets little or no pain relief from weight loss, medication, or other therapies, is in severe pain and has lost a lot of cartilage, joint surgery may be recommended.
For More Information
How Pharmacists Can Help You Safely Juggle Multiple Meds (Arthritis Today)