Medications for Osteoarthritis: Relieving the Pain Developed by: Eugene B Smith Jr, PharmD , MPH, Associate Professor Laura Jones, MPH, Extension Assistant Bobbi Clarke, PhD, RD, Professor and Extension Health Specialist UT Center for Community Health Literacy

What is Osteoarthritis? Osteoarthritis (OA) is the most common form of arthritis It is the progressive loss of cartilage in the joints OA is also known as “degenerative joint disease” Over 60% of people over 65 have some form of arthritis Cartilage is the slippery material that cushions the ends of the bones in the joint. Many different types of arthritis- this information is meant to specifically refer to OA.

Osteoarthritis Pain The motivation for most OA therapy is pain improvement/relief This cycle represents common problems that can make pain worse You can break the cycle at any point with a variety of self-help strategies Pain does not have to control your life The Cycle of Pain Disease Fatigue Tense Muscles Depression Stress/Anxiety Difficult Emotions

Breaking the Pain Cycle The Arthritis Self-Help Program is designed to present practical ways that you can break the arthritis pain cycle and regain control of your pain, such as: Exercise Adequate rest Healthy diet/weight loss Relaxation Techniques Positive Self Talk Mental techniques to fight pain Physical Therapy Drug therapy Surgery

Exercise and Weight Loss One of the most effective ways to help arthritis! Helps reduce stiffness, increases flexibility and prevents falls Weight Loss: Research studies have shown that even a 10% loss of weight can improve OA symptoms by 50%!! Exercise is very important for the treatment of OA. Part of the goal of drug therapy is to relieve pain so that you can exercise the way you want to.

Drug Therapy Medications are an important strategy for breaking the pain cycle Keep in mind- unfortunately, we do not have any drugs that reverse the progression of OA The main goal of drug therapy: To relieve pain and help patients exercise and keep the joints functioning

Drugs used for OA Acetaminophen Topical pain relievers Non Steroidal Anti-inflammatory Drugs (NSAIDs) Corticosteroids Hyaluronic acid Narcotic pain relievers

Acetaminophen Acetaminophen (Tylenol) is available OTC and has been the best drug for treating the pain of OA for a long time Be careful to use the right dose: Read the dosage on the package carefully Start with small doses even as little as one 500mg dose can be effective Do not exceed 4000 mg in any daily dosage.

Use Caution… Sometimes people develop a tolerance to pain relievers and need a higher dose to relieve the pain Doses over 4000 mg/day of Acetaminophen damage the liver and can cause death! Many drugs contain Acetaminophen. Be sure to read labels and know how much you are getting in a day from all your medications Long term use may also cause Kidney damage: The July 26,2004 issue of Archives of Internal Medicine reported that long-term habitual use of acetaminophen may cause a decline I kidney function in some people. Overall one in 10 of the 1700 women studied over 11 years experienced a 30% decline in GFR In the study , women who had taken between 1500 and 9000 tablets over their lifetime raised their risk of kidney impairment by 64% For those who took more than 9000 tablets , their risk more than doubled

Topical Treatments There are a variety of things that can be applied to the affected joint that will relieve pain: Heat and ice Lidocaine patches Topical NSAIDS (not for long-term relief) Capsaicin (Zostrix) A skin cream made from hot peppers that relieves pain and possibly reduces inflammation over time

The Clock is Ticking… Studies show that Topical NSAIDs used in OA are only effective during the first 2 weeks of therapy!!

Glucosamine & Chondroitin Are they effective when taken together?? Many patients claim they help Some studies have shown slowed progression of joint disease However, other studies have shown only limited effectiveness in treating pain Such as the NIH GAIT study which showed them to be better than placebo (60% improvement compared to 50% for placebo)

Glucosamine In the US, Glucosamine is considered a dietary supplement (not a drug) and does not have to be proven to be effective to be sold Worstpills.org (a Consumer Reports website) advises consumers to avoid glucosamine due to lack of proven effectiveness

What if I decide to give it a try? Buy a supplement that contains glucosamine only- it will be cheaper and no studies have shown chondroitin to be effective by itself You should try it for a minimum of 8 weeks and keep a diary to see if you are feeling better Buy a tested brand: See www.consumerlab.com for comparisons

NSAIDS “NSAID” stands for: Non-Steroidal Anti-Inflammatory Drug(s) Different classes of NSAIDS: Non-selective NSAIDS: Ibuprofen (OTC) Naproxen (OTC) Indomethacin (Must be prescribed) Selective “COX-2” inhibitors: Celebrex , Vioxx, and Bextra General NSAIDS inhibit both COX-1 and COX-2. Inhibition of COX-1 produces the undesirable effect of stomach ulcers.

Are NSAIDs Safe? In general, NSAIDS are good class of drugs because they treat pain and reduce inflammation Negative side effects: Non-selective NSAIDS Stomach upset/bleeding/ulcers Selective “COX-2” drugs: Possibly increase heart attack/disease risk

FDA Verdict on Cox-2 Drugs In 2005, the FDA recommended that warnings appear on the labels of Selective Cox-2 inhibitors concerning their heart risks and requiring each prescription to have a guide describing the risks They recommended that non-selective NSAIDS carry the same warnings Fate of Cox-2 Inhibitors: Vioxx and Bextra were taken off the market Only Celebrex remains

Corticosteroids These drugs are naturally occurring substances in the body but as drugs they have been further refined to make them more effective. Examples: Prednisone , Hydrocortisone, Betamethasone, Methylprednisiolone, Triamcinolone,etc They can be used orally or by injection for OA. They have significant side effects so they should used sparingly (intra-articular injection every 3-6 months)

Hyaluronic acid This agent is used by injection into the joints in patients with severe disease and has many advantages but must also be used sparingly. It is used to replace lost fluid in the joint spaces and keep the joint working to cushion the bones in the joint.

Narcotic pain relievers These drugs are reserved for moderate to severe pain after the other options have not worked. Why?: They make you sleepy and this reduces the ability to drive, work, or exercise Side effects include: anxiety, constipation, nausea and vomiting, & urinary retention Tolerance develops soon and treating OA is a lifetime process

Conclusion The use of drugs for OA is a proven treatment approach. Recent news releases have reminded us that drugs in these classes have significant side effects that we must be concerned about when we use these drugs. Take care to use drugs wisely!