Acetaminophen (Tylenol, generic) is the first choice for treating mild-to-moderate osteoarthritis pain. (Acetaminophen may be less effective than NSAIDs in reducing moderate-to-severe pain.) Because acetaminophen has fewer side effects, most doctors suggest trying this drug first, then switching to an NSAID if acetaminophen does not provide sufficient pain relief. Acetaminophen is an analgesic that helps relieve pain but unlike NSAIDs it does not help reduce inflammation.
Side Effects. Acetaminophen is inexpensive and generally safe. It poses far less of a risk for gastrointestinal problems than NSAIDs.
The daily dose of acetaminophen should not exceed 3,000 mg. Patients who take high doses of this drug for long periods are at risk for liver damage, particularly if they drink alcohol and do not eat regularly. Long-term, high-dose acetaminophen therapy may increase the risk for high blood pressure.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. There are dozens of NSAIDs:
- Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Motrin, generic), naproxen (Aleve, Naprosyn, generic), ketoprofen (Actron, Orudis KT, generic).
- Prescription NSAIDs include flurbiprofen (Ansaid, generic), diclofenac (Voltaren, Cataflam, Arthrotec, generic), tolmetin (Tolectin, generic), ketoprofen (Orudis, generic), nabumetone (Relafen, generic), indomethacin (Indocin, generic), meloxicam (Mobic, generic).
- Topical NSAIDs are gels, creams, or patches that are available either by prescription or over-the-counter. The American College of Rheumatology recommends the use of topical NSAIDs such as trolamine salicylate (Aspercreme, Myoflex, generic) for hand or knee osteoarthritis. (See Capsaicin section below for safety information about these products.)
- Coxibs are a newer type of NSAID that inhibit an inflammation-promoting enzyme called COX-2. This drug class was initially thought to provide benefits equal to NSAIDs but cause less gastrointestinal distress. However, following numerous reports of cardiovascular events, as well as skin rashes and other adverse effects, most COX-2 inhibitors were withdrawn from the market. Celecoxib (Celebrex) is still available, but patients should discuss with their doctors whether this drug is appropriate and safe for them
Oral NSAIDs should be used only for a short period of time. Long-term use of NSAIDs does not delay the progression of osteoarthritis and can increase patients' risk of side effects.
Patients should use only the lowest effective dose because high dosages of NSAIDs can cause heart problems (such as increased blood pressure and risk of heart attack), kidney problems, and stomach bleeding. Because of these risks, the American College of Rheumatology recommends using topical NSAIDs in place of oral NSAIDs for patients 75 years and older.
Patients who take daily low-dose aspirin for heart protection should consider using an oral NSAID other than ibuprofen. Ibuprofen may make the aspirin less effective.
Patients who are at increased risk of stomach bleeding and ulcers should either switch to another type of pain reliever, or take the NSAID along with a proton-pump inhibitor drug, such as omeprazole (Prilosec, generic) or esomeprazole (Nexium), an H2 blocker such as famotidine (Pepcid, generic), or with the synthetic prostaglandin misoprostol (Cytotec, generic). (Misoprostol can cause miscarriage and should not be used by women who may be pregnant.) Some NSAIDs are available as combination pills; they include diclofenac/misoprostol (Arthrotec) and ibuprofen/famotidine (Duexis).
Capsaicin and Other Topical Products
Capsaicin is a component of hot red peppers and may bring pain relief when used as a skin cream (Zostrix, generic). This is the only skin preparation that does more than just mask pain or reduce it temporarily. Capsaicin seems to reduce a substance in the body, known as substance P, which contributes both to inflammation and the delivery of pain impulses from the central nervous system.
A small amount of capsaicin must be applied to the area of inflammation about four times a day. During the first few days of use, the patient will experience a warm, stinging sensation when the cream is applied. This sensation goes away, and pain relief usually begins within 1 - 2 weeks. The American College of Rheumatology recommends topical capsaicin for hand osteoarthritis but not for knee or hip osteoarthritis.
Topical over-the counter joint pain relievers that contain menthol, methyl salicylate, and (less commonly) capsaicin may in rare cases cause chemical burns. Menthol and methyl salicylate products are sold under brand names such as Bengay, Flexall, Icy Hot, and Mentholatum. Products that contain capsaicin include Capzasin as well as Zostrix. The risks appear more severe for combination products that contain higher doses of both menthol (greater than 3%) and methyl salicylate (greater than 10%). The FDA recommends:
- Don’t apply these products to damaged or irritated skin
- Don’t apply bandages, heating pads, or hot water bottles to areas treated with these products
- If you see any signs of blisters or burns, stop using the product and seek medical attention.
These warnings also apply to the topical NSAID products that contain trolamine salicylate (see NSAIDs section above).
Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressant that is used to treat depression, anxiety disorders, diabetic nerve pain, and fibromyalgia. In 2010, the FDA approved duloxetine for treatment of chronic musculoskeletal pain associated with osteoarthritis.
Tramadol (Ultram, generic) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet, generic) is available.
Narcotics, pain-relieving and sleep-inducing drugs that act on the central nervous system, are the most powerful medications available for the management of moderate-to-severe pain. There are two types of narcotics:
Opiates, which are derived from natural opium (morphine and codeine)
Opioids, which are synthetic drugs. They include oxycodone (such as Percodan, Percocet, Roxicodone, OxyContin, generic), hydrocodone (Vicodin, generic), oxymorphone (Numorphan, Opana), and fentanyl (Duragesic, generic)
Although the use of narcotics for arthritic pain is controversial, they may have a place in osteoarthritis treatment when milder drugs are not effective or appropriate. These drugs can be highly addictive, and should be prescribed at the lowest possible effective dose.
Common side effects include anxiety, constipation, nausea and vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing.
When pain becomes a major problem and less potent pain relievers are ineffective, doctors may try corticosteroid (steroid) injections into the joint. Corticosteroid shots are useful only if inflammation is present in the joint. Relief from pain and inflammation is of short duration, and this treatment is rarely used for chronic osteoarthritis. The American College of Rheumatology does not recommend these injections for hand osteoarthritis.
Corticosteroid injections are usually given every 3 months. Patients should not have more than two or three injections a year, since there is some concern that repeated injections over the long term may be harmful. Because long-term use of corticosteroids has many potentially serious side effects, steroid medications are never given by mouth (systemically) for the treatment of osteoarthritis.
Hyaluronic Acid Injections (Viscosupplementation)
Injections of hyaluronic acid (such as Hyalgan, Synvisc, Artzal, and Nuflexxa) into the joint -- a procedure called viscosupplementation – are a controversial treatment for knee osteoarthritis. Evidence indicates that these injections provide only very modest short-term pain relief at best. Some studies suggest these injections may increase the risk for swelling and inflammation. The American Academy of Orthopedic Surgeons no longer recommends viscosupplementation as a treatment for patients with symptomatic osteoarthritis of the knee.