Posted on: April 30th, 2014 by Dr. Richard R. Olson Show
This is the second part of my survey of your osteoarthritis medication options. Read part 1 here. Part 2 focuses more on potent medications. Always check with your rheumatologist before beginning any medication regimen. TramadolThis is a medium potency analgesic with low risk of dependency. It has no effect on inflammation. Nausea is a possible side effect, which can be minimized by starting at low doses, and sedation may occur in some patients. The use of higher than recommended doses can increase risk of seizures. On the plus side, combining it with acetaminophen can improve pain relief. NarcoticsNarcotic agents are the most potent pain medications available. These work in the brain in the same manner as morphine, and they do pose a risk of dependency. Sedation and constipation are possible, especially at higher doses. These medications have been abused and obtained due to their significant abuse potential. Physicians prescribe narcotics only to selected patients that use them exactly as prescribed and maintain regular follow-up. Nerve blocking agentsMedications originally developed to treat seizure disorders have been shown to dampen sensitivity of nerves and ease pain levels in people with chronic arthritis pain. Gabapentin (Neurontin®) and pregabalin (Lyrica®) are two options that can be used alone or in conjunction with other medications. They can be sedating, and for some patients a bedtime dose will improve sleep disorders or restless leg symptoms, but make sure to ask what your limitations will be. Response to these medications varies between patients, so initially small doses are used with gradual increase to obtain the best effect. At high doses, these options have a risk of excessive sedation or loss of mental clarity. Muscle relaxersMuscle spasm and muscle pain are common in patients with arthritis. Bedtime dosing of muscle relaxers such as cyclobenzaprine or tizanidine can lower pain levels and also improve sleep quality. Due to possible sedation, daytime dosing is less useful for most patients. Serotonin medicationsMedications used for the treatment of anxiety and depression can also help arthritis discomfort, including chronic pain due to osteoarthritis. In chronic pain, brain serotonin levels are reduced–similar to people with depression symptoms. Duloxetine (Cymbalta®) received FDA approval for both Fibromyalgia and chronic musculoskeletal pain. Your response to specific agents will vary, so a trial of more than one option is advised even if one of these is not helpful. Sleep medicationsIf you have osteoarthritis, you know that your arthritis pain can disrupt sleep, leading to fatigue and greater pain sensitivity. Medications that improve sleep quality- nerve blocking agents, muscle relaxers, serotonin medications (above)- often improve both your pain and energy levels. Joint injectionsCortisone is an anti-inflammatory medication that is injected directly into painful joints to provide temporary relief of pain. Knees and shoulders are most commonly injected, but other joints can be injected by an experienced physician. Pain relief can vary from several days to several months following injection. Most people tolerate cortisone fairly well, but it may cause temporary flushing and can cause increased blood sugar in diabetic patients. Viscosupplements are newer medications that are approved only for osteoarthritis of the knee. They are all forms of Hyaluran, a protein found in normal, healthy joint fluid. Compared to cortisone, pain reduction can last longer- up to 6 months. However, as with other medications, there is no evidence that Hyaluran injections result in repair of damaged cartilage. US Pharm. 2006;5:49-55. Osteoarthritis is a common rheumatologic disorder. It is characterized by a gradual loss of cartilage from the joints and, in some people, joint inflammation. Symptoms of osteoarthritis include pain, stiffness, and loss of joint motion. It is estimated that 40 million Americans of all ages are affected by osteoarthritis and that 70% to 90% of Americans older than 75 have at least one joint involved.1 In the United States, women are more often affected by osteoarthritis, and older women are twice as likely to be affected by osteoarthritis of the hands and knees than comparably aged men.2 As the population of elderly patients continues to grow, osteoarthritis becomes a significant medical and financial concern. With recent issues surrounding NSAIDs and cyclooxygenase-2 (COX-2) inhibitors, managing osteoarthritis is now more complex and individualized. This article briefly discusses the background, prevalence, and diagnosis of osteoarthritis, then focuses on the treatment options available for this disease. PREVALENCE PATHOPHYSIOLOGY Early changes to the joints do not result in any symptoms, since there are no nerve fibers in articular cartilage. Potential sources of pain in osteoarthritis include denuded bone, microfractures of bone, stress to ligaments due to loss of cartilage, low-grade synovitis, and spasms of surrounding muscles as the disease progresses. CAUSES AND CLINICAL FEATURES
Patients with osteoarthritis of the hip may complain of gait problems. After a period of inactivity, hip stiffness is common and is usually a presenting factor. Patients with osteoarthritis that affects the hands often have problems with manual dexterity. This is evident when the first carpometacarpal joint is involved. Instability or buckling of the knee is often noted in patients with knee osteoarthritis. Some patients with erosive osteoarthritis may have signs of inflammation in the interphalangeal joints of the hands. However, osteoarthritis generally does not carry an inflammatory component, except in severe, advanced disease. Radiographic features and laboratory findings are not definitive in the diagnosis of osteoarthritis. Radiographic features of the disease show loss of joint space and presence of new bone formation or osteophytes. However, absence of these radiographic changes does not exclude a diagnosis of osteoarthritis. Analysis of synovial fluid tends to reveal a white blood cell count of less than 2,000 per millimeter.4 DIAGNOSIS TREATMENTS Nonpharmacological Treatment
Patient Education: Education about the causes, effects, and symptoms of osteoarthritis, as well as a realistic understanding of what can be achieved with optimal therapy, is essential. Osteoarthritis has both physical and psychological effects. Its symptoms and limitations may cause feelings of frustration, dependency, and even depression. The more patients learn about the disease, the more they can participate in their own care. Social support can be achieved by building an informal support team or by participating in formal osteoarthritis groups. Weight Loss: Although obesity appears to be a greater risk factor for women, an association exists between obesity and osteoarthritis of the knee in both genders.10 Weight loss has been shown to benefit patients with osteoarthritis.11 Symptoms associated with arthritis in the hips, knees, and feet are exacerbated by obesity. Thus, primary prevention strategies should include measures to achieve weight loss or avoid weight gain in overweight patients. Assistive Devices: A variety of appliances can help relieve osteoarthritis symptoms by supporting the muscles linked to the affected joint. Examples of assistive devices include crutches, walking aids, shoes inserts, splints, braces, and special soles.11 Using special appliances may help patients feel more comfortable, move around independently, and have improved function. Physical and occupational therapy may benefit patients with specific physical disabilities brought on by osteoarthritis. Incorporating individualized exercise programs and teaching patients how to manage activities of daily living may lead patients to feel more independent and less affected by their disease. Alternative Therapy Supplements: Patients often seek alternative therapies for osteoarthritis after experiencing side effects or incomplete relief of symptoms from conventional medications. Since the herbal and supplement industry is not regulated by the FDA, supplement composition can vary. Glucosamine sulfate, a popular treatment for osteoarthritis symptoms, is derived from oyster and crab shells. No published studies have documented arthroscopic improvement in arthritic cartilage with glucosamine use in humans. A meta-analysis concluded that glucosamine may show efficacy over placebo in relieving painful symptoms. 12 Glucosamine is usually dosed at 1,500 mg per day in three divided doses. Supplements should be taken for at least a month before improvement occurs. Chondroition sulfate has demonstrated efficacy by acting as a building block of proteoglycan molecules to improve the symptoms of osteoarthritis.13 Chondroitin is derived mostly from shark and cow cartilage. Chondroitin is usually dosed at 1,200 mg per day in three divided doses, and results may not be achieved for at least a month. Little evidence exists showing that the combination of glucosamine and chondroitin is more effective than either supplement alone.14 However, the use of the two together is popular for the treatment of osteoarthritis. The Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT) was a six-month, five-arm trial involving 1,500 osteoarthritis patients with mild to severe pain. Patients were given glucosamine, chondroitin, glucosamine and chondroitin combined, celecoxib, or placebo daily. The GAIT abstract posted on the ACR Web site concludes that glucosamine and chondroitin together are beneficial in treating moderate to severe knee pain due to osteoarthritis. Results have yet to be presented. S-adenosylmethionine (SAMe) is a naturally occurring compound found in all living cells that is commercially produced in yeast-cell cultures. Several studies have found SAMe to be more effective than placebo in improving pain and stiffness related to osteoarthritis.15,16 Dosages range from 400 to 1,200 mg per day. Pharmacological Treatment
Analgesics, NSAIDs, and COX-2 Inhibitors: The nonprescription analgesic acetaminophen, at doses of 1,000 mg four times a day or 650 mg every four hours (up to a maximum of 4 g/day), is the drug of choice for pain relief for noninflammatory osteoarthritis. The ACR guidelines emphasize the use of acetaminophen as first-line treatment for osteoarthritis of the knee and hip.17 This analgesic can significantly improve function and decrease pain. Therapeutic doses of acetaminophen produce minimum adverse effects, but hepatotoxicity can occur, especially in patients who consume large quantities of alcohol. NSAIDs are appropriate choices for treating moderate or severe arthritis pain, as well as the swelling, stiffness, and warmth of inflammation when present. NSAIDs carry a risk of gastrointestinal (GI) toxicity, even at a low dose. GI complications occur over the course of one year in about 2% to 4% of patients, and incidence increases with age.9 Reduced prostaglandins in the gastric mucosa from COX inhibition attributes to the GI side effects of NSAIDs. Proton pump inhibitors may help control the GI symptoms associated with chronic NSAID use. Misoprostol, a synthetic prostaglandin E1, can help prevent gastric ulcers in patients on long-term NSAID therapy. Several risk factors appear to increase the risk of NSAID-induced toxicity, especially in patients over age 65; patients with previous ulcer or upper GI bleeding; and patients taking concomitant oral cortico steroids, anticoagulants, or multiple NSAID therapy. 18 The ACR guidelines recommend starting NSAIDs at low analgesic doses and increasing to full anti-inflammatory doses only if the lower dose did not provide adequate relief.17 The concurrent use of acetaminophen with NSAIDs may allow the NSAID dosage to be reduced, thereby limiting toxicities. COX-2 inhibitors may be appropriate to initiate for patients with moderate to severe pain when non selective COX inhibitors have proven ineffective or for those patients who have a history of GI disease. COX-2 inhibitors have at least a 200- to 300-fold selectivity for inhibition of COX-2 over COX-1. Celecoxib is recommended in doses of 200 mg per day for the treatment of osteoarthritis pain. COX-2 inhibitors are associated with lower gastroduodenal toxicity, but an increased risk of cardiovascular events has led to the withdrawal of two previous agents (rofecoxib and valdecoxib) from the market. Although elderly patients may choose to use celecoxib because of less GI effects, they need to be made aware of the risks and benefits by their physician before beginning treatment. Treatment options for osteoarthritis have been further complicated by the potential cardiovascular risk associated with the use of naproxen and other NSAIDs. All NSAIDS, both over-the-counter and prescription, and COX-2 inhibitors carry a warning regarding cardiovascular and GI risks.19 Tramadol is usually given as a rescue medication for symptomatic relief and can be considered an option if NSAIDs fail. Use of this central-acting oral analgesic allows for a lower dose of NSAIDs to be used. The recommended dose is 50 mg given every four to six hours, with a total daily dose not exceeding 400 mg.9 Opioids can be considered for patients with severe osteoarthritic pain that does not respond to nonopioid analgesic agents. These agents are not recommended for prolonged time periods because they cause constipation and increase the fall risk, especially in the elderly. Topical capsaicin, a pepper-plant derivative, has been shown to relieve pain relating to osteoarthritis better than placebo. Capsaicin cream 0.025% applied four times a day was effective in managing pain caused by osteoarthritis of the knee, ankle, wrist, and shoulder in a double-blind, randomized, controlled trial. 20 One common side effect is a localized burning sensation, and patients should be advised to wash hands after application to avoid spreading to the eyes or other mucous membranes. Capsaicin is available over the counter in concentrations of 0.025%, 0.075%, and 0.25%. Intra-Articular Glucocorticoids and Hyaluronate: Patients who suffer from painful flares of osteoarthritis in the knee may benefit from intra-articular injections of corticosteroids, such as methylprednisolone or triamcinolone. Short-term pain relief can be obtained with aspiration of the joint fluid, followed by intra-articular injection of the corticosteroid when the joint is painful and swollen. Injections should not be made in the joints more than three or four times a year, to prevent potential cartilage damage from repeated injections. Patients may have to consider surgical intervention if they require more than three to four shots per year to control symptoms. Hyaluronic acid provides viscoelastic and lubricating properties to the joint. It is a major nonstructural component of the synovial and cartilage matrix makeup. The molecular weight and concentration of hyaluronic acid is thought to be decreased in patients with osteoarthritis. The FDA has approved hylan G-F 20 and sodium hyaluronate injections for the treatment of pain caused by osteoarthritis of the knee. The 2-mL dose is injected once weekly for three and five weeks, respectively. The injections are well tolerated; however, local skin reactions and pain with injection have been shown. Intra-articular injections must be administered using the aseptic technique, and the aspirated joint fluid should be examined to rule out infections. Patients should minimize activity and stress on the joint for several days following an intra-articular injection. Surgery
Conclusion REFERENCES 905-911. To comment on this article, contact . What is the best drug treatment for osteoarthritis?Nonsteroidal anti-inflammatory drugs (NSAIDs).
Over-the-counter NSAIDs , such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), taken at the recommended doses, typically relieve osteoarthritis pain. Stronger NSAIDs are available by prescription.
What medications would the patient be prescribed for osteoarthritis?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, celecoxib, ibuprofen, and naproxen.
Which medication is considered the primary drug of choice for treatment for a patient with osteoarthritis OA )?At present, acetaminophen (up to 4,000 mg/daily) is the recommended initial analgesic of choice for symptomatic OA. ( ACR Guidelines-Guidelines for Medical Management of OA of the knee) However, many patients eventually require NSAIDs or more potent analgesics to control pain.
Do muscle relaxers help with osteoarthritis pain?Muscle relaxers are sometimes prescribed for people with osteoarthritis pain and other types of musculoskeletal pain. They are available by prescription only and intended for short-term use.
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