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The Medical Management of Osteoarthritis:
What is Safe – What is Effective – What I Would Do
Richard A. Sweet, MD
Louisville Orthopaedic Clinic - Louisville, KY
Osteoarthritis affects over 30 million Americans. More than 50% of people over 65 years of age have been diagnosed as having arthritis. It is a leading cause of disability and suffering in the US. As baby boomers age, the ravages of arthritis have resulted in an explosion of joint replacement surgery and spine surgery to deal with it. However most arthritic sufferers either do not need surgery or have a problem not amenable to surgical management. For those patients, the medical treatment of their disease becomes increasingly important.
There are several problems associated with the medical treatment of the pain and inflammation of osteoarthritis.
- First and perhaps most importantly, the available drugs are only modestly effective. As the arthritic condition becomes more severe, these drugs become increasingly less effective (hence the frequent need for joint replacement surgery).
- Second, available drugs to treat osteoarthritis do not cure, reverse or even slow the progression of arthritis. This needs be kept in mind when considering possible side effects of these drugs described below.
- Third, there are a host of side effects and complications associated with use of these drugs.
The Benefit of Arthritis Drugs
The major benefit of drugs used to treat arthritis is simple. They help. When using these drugs, patients with arthritis feel better, have less joint pain, can stay more active and can even rest and sleep better.
Types (Classes) of Drugs
There are three basic classifications of drugs used to treat non rheumatoid osteoarthritis
- Non-Steroidal Anti Inflammatants (NSAIDS)
- Acetaminophen (Tylenol)
Drugs of this class, typified by the drug prednisone, are the most effective drugs to treat symptoms of arthritis. However, they also have the most serious potential side effects when over utilized or taken over too long of a time period. Steroids are most often used in a “burst” fashion, such as a tapering 6-7day dose pack (Medrol Dose Pack). It has been shown that this “burst” strategy maximizes effectiveness while minimizing potential side effects. The side effects of steroid over use are too long to list here. Suffice it to say that over use of steroids negatively impacts every organ and anatomic structure in the body. It can thin skin and weaken bone. Steroids make management of diabetes more difficult and cause weight gain. There is almost no part of the body unaffected by chronic steroid use. BUT, keep in mind steroids are the most potent drug available to treat the inflammation of arthritis. When taken judiciously, steroids can safely help in the management of the pain and disability of arthritis.
Non-Steroidal Anti Inflammatants (NSAIDS)
There are a multitude of drugs available in this class. Three are over the counter and the rest are all prescription drugs. Here is the secret: they are all equally effective, including the over the counter drugs. The three over the counter options include ibuprofen (Advil & Motrin are common trade names), naproxen (Aleve) and aspirin products. Ibuprofen & naproxen were released by the FDA many years ago at what is, compared to their prescription brethren, half strength. The ibuprofen 200 mg products are recommended on the label to take two pills at a time (400 mg). Prescription strength is 800 mg (4 of the over the counter pills). Over the counter naproxen 220 mg is recommended to take one pill at a time, again roughly half the 500 mg prescription strength. Thus “doubling up” on label recommendations for over the counter ibuprofen & naproxen get the patient to a prescription level strength (and prescription level side effect risk) Prescription NDAIDS include Mobic (meloxicam), Voltaren, and Celebrex among a whole host of others.
Effectiveness of NSAIDS
NSAIDS are effective. To a point. They do help reduce joint inflammation, swelling, stiffness and soreness. Once the arthritis reaches a certain level of severity, however, their effectiveness diminishes. As noted, NSAIDS to not cure, slow or reverse the progression of arthritis.
Risks of NSAIDS
I am not a pharmacologist. This is not an all-inclusive list. But here are common (and potentially significant) potential issues with taking NSAIDS.
- Sodium retention – some patients with difficult to treat high blood pressure are advised to stay away from NSAIDs.
- Ringing in the ears (tinnitus). This is usually reversible one NSAIDs are stopped.
- Kidney & liver damage – very rare, but patients on long term NSAIDS should be followed by their primary care provider
- Gastrointestinal issues – All NSAIDS except Celebrex are in a class called Cox-1 inhibitors. These drugs cause gastritis, aggravate reflux or can cause stomach ulcers in up to 20% of patients. Celebrex, in a class called Cox-2 inhibitors, causes GI issues in only 1% of patients (the trade off – Celebrex may have a higher risk of heart issues – see below).
- Blood thinning – All NSAIDS (except Celebrex) thin the blood by affecting platelet function.
- Cardiac risks – Heart risks associated with these drugs have only recently been appreciated. It was first noted that the Cox-2 inhibitors were most at risk for patients developing heart attacks and strokes. Cox-2 inhibitors Vioxx and Bextra were pulled off the market. Celebrex, also in this class drug, somehow avoided recall. It is now known that, except for aspirin, all NSAIDS carry some risk of causing cardiovascular disease. There is some evidence that naproxen may carry slightly less risk. Only aspirin, long known for its cardiovascular protective properties, seems completely safe from the risk of heart issues.
Tylenol is a mild pain reliever. It does not suppress inflammation. Thus theoretically it is not quite as effective as NSAIDS, which both relieve pain & suppress inflammation. The maximum daily dose of acetaminophen is 3000 mg. A major risk of this drug is liver damage. It does not have the GI risks associated with NSAIDS.
What I Recommend
I have dealt (fairly successfully) with 25 years of back issues and more recently with a right hip going bad. As my wife would tell you, to say that I remain active is the world’s greatest understatement. How? I stay fit and in shape. I stay away from activities and exercise programs I know likely to aggravate things (OK, except for an occasional 36 holes a day golf excursion with my buddies). And I utilize a very judicious medical management program. For the most part, I don’t take any medications. If I get sore enough, I might take a few days of NSAIDS. I used to solely take over the counter naproxen, then it started upsetting my stomach. I switched to very occasional use of Celebrex, but I'm worried about its heart related side effects. Though I still occasionally resort to Celebrex or naproxen, currently I'm trying to take 2 regular strength (325 mg) aspirins when needed with medication to protect my stomach (that is a whole other subject, as one of the two classes of the over the counter stomach protective medications may have its own cardiac risks – I take Zantac (ranitidine) which is over the counter and seems to have the least associated risks). Only rarely will I feel the need to take a Medrol steroid pack. Bottom line, I take no more of any of these meds than I have to. When needed though and when used in moderation the available arthritis meds can and do help me, and they can help you.