Osteoarthritis

A variety of medications are available to treat osteoarthritis pain, including:

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). These are among the most common treatments for osteoarthritis pain.  Purchased over-the-counter or by prescription, NSAIDs — such as aspirin, ibuprofen (Advil or Motrin) and diclofenac (Cataflam, Voltaren) — act quickly to relieve pain. There are more than 30 drugs classified as NSAIDs and each has a slightly different chemical structure, is metabolized differently and seems to work differently among patients. (Other drugs, such as methotrexate, chloroquine, pencillamine and gold salts, work through the immune system and have some anti-inflammatory effects.) For severe osteoarthritis pain, the NSAID ketorolac (Toradol) can be given as an injection for speedy, although brief, pain relief.

Comments:

• Aspirin is probably the least expensive NSAID available. Its active ingredient is synthesized from salicin, a natural substance found in willow bark and other plants. Americans take more than 30 billion aspirin tablets a year at a cost of $1 billion. However, aspirin has multiple side effects – so many, in fact, that the drug probably would not receive modern-day U.S. Food and Drug Administration approval.  While low doses of aspirin appear to help prevent heart attacks and may help prevent colon cancer and Alzheimer's Disease, aspirin can cause gastrointestinal problems and trigger life-threatening allergic reactions in some people. (See Arthritis Books and Videos for more information about aspirin.)

• Long-term use of NSAIDs can cause complications in arthritis patients. These can range from minor bleeding in the gastrointestinal tract, to liver or kidney toxicity (poisoning).  In fact, stomach irritation is so common with frequent NSAID use that some doctors also prescribe misoprostol (Cytotec), a drug that protects the stomach lining.  (Misoprostol has its own potential side effects, including nausea, gas, headaches and vomiting; it can cause miscarriage and should never be given to pregnant women).  One prescription product, approved in just the past few years, combines the NSAID diclofenac sodium with misoprostol and is marketed under the name Arthrotec. One of the newest NSAIDs, celecoxib (Celebrex), are reported to be easier on the stomach than older NSAIDs.

• NSAIDs also can interact with other drugs, even over-the-counter preparations.  Antacids, for example, can decrease the absorption of NSAIDs, reducing their pain-fighting effect.  Prescription medicines also can have adverse effects when mixed with NSAIDs.  NSAIDs can augment the action of diuretics, lithium, oral hypoglycemic agents and phenytoin (Dilantin).

• It is extremely important to follow all the label instructions and cautions when taking NSAIDs and to consult with your health care provider if you have any concerns.

Oral Tramadol (Ultram). Available for moderate to severe pain. 

Comments: When introduced to the United States in 1966, the U.S. Food and Drug Administration classified tramadol as a non-narcotic drug. However, some cases of addiction have been reported. Tramadol also has been linked to seizures in susceptible individuals, especially when the drug is given at high doses.  The risk of seizure is higher in patients who are also taking antidepressant drugs such as desipramine (Norpramine) or doxepin (Sinequan).  Caution also has been advised with well-known antidepressants fluoxetine hydrochloride (Prozac), sertraline hydrochloride (Zoloft) and paroxetine (Paxil). 

Narcotic Drugs - Opioids. When pain is extreme, narcotic drugs derived from opium may be prescribed. For arthritis, the most common narcotics prescribed are propoxyphine (Darvon), codeine (Tylenol #3 or #4) or hydrocodone (Vicodin and Lorcet), although oxycodone (Percodan and Percocet) is being prescribed more often now.  These narcotic drugs bring swift pain relief, allowing the patient more activity during the day and better sleep at night.

Comments: Opioids can have side effects and may lead to dependency, but rarely addiction.  Prescribing them should be done only when more conservative treatment has failed, and a patient understands the risks and rewards involved in their use. Opioids are being used more often in advanced arthritis. (See the Arthritis Library for more information about opioids.)

Mixed Agonists/Antagonists (Synthetic Narcotics). This class of drugs is used at times for arthritis pain.  They include pentazocine (Talwin-NX or Talace), nalbuphine (Nubain), butorphanol (Stadol or Stadol NS) and buprenorphine (Buprenex). Only pentazocine is available in oral form and likely to be useful on in some cases of advanced arthritis. 

Comments: This group of drugs has what is called a "low ceiling effect," meaning a small dose may be helpful, but more can cause complications. They also cannot be mixed with strong natural opioids.

Viscosupplements. Two agents have been approved by the FDA for osteoarthritis of the knee.  They are injected into the knee to replace the hyaluronic acid, a substance that gives the knee joint viscosity, and which appears to break down in osteoarthritis.

The two viscosupplements currently on the market are Hyalgan and Synvisc.  For Hyalgan, five injections over 6-10 weeks are needed, and for Synvisc, only three injections are needed.

Glucosamine sulfate. One of the most exciting recent developments in arthritis treatment, glucosamine has been shown to relieve pain and potentially rebuild damaged cartilage. Available without a prescription, glucosamine is found in high concentrations in seashells, from which glucosamine is harvested. Glucosamines are used by the body to manufacture proteoglycans, substances that hold collagen threads together. Collagen is an element of cartilage.  Some studies have shown that glucosamine sulfate actually "feeds" the joints and stimulates regrowth at the cellular level.  Glucosamine sulfate also matches NSAIDs in providing long-lasting pain relief, researchers have found — and without NSAIDs' side effects.

A powdered form of glucosamine sulfate, which can be mixed into juice, is expected to be available soon.  Glucosamine sulfate is used to treat patients of all ages and all stages of osteoarthritis.

Rheumatoid Arthritis

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). These are among the most common treatments for osteoarthritis pain.  Purchased over-the-counter or by prescription, NSAIDs — such as aspirin, ibuprofen (Advil or Motrin) and diclofenac (Cataflam, Voltaren) — act quickly to relieve pain. There are more than 30 drugs classified as NSAIDs and each has a slightly different chemical structure, is metabolized differently and seems to work differently among patients. (Other drugs, such as methotrexate, chloroquine, pencillamine and gold salts, work through the immune system and have some anti-inflammatory effects.)  For severe rheumatoid arthritis pain, the NSAID ketorolac (Toradol) can be given as an injection for speedy, although brief, pain relief.

Comments:

•  Aspirin is probably the least expensive NSAID available. Its active ingredient is synthesized from salicin, a natural substance found in willow bark and other plants. Americans take more than 30 billion aspirin tablets a year at a cost of $1 billion. However, aspirin has multiple side effects – so many, in fact, that the drug probably would not receive modern-day U.S. Food and Drug Administration approval.  While low doses of aspirin appear to help prevent heart attacks and may help prevent colon cancer and Alzheimer's Disease, Aspirin can cause gastrointestinal problems and trigger life-threatening allergic reactions in some people. (See the Arthritis Library for more information about aspirin.)

• Long-term use of NSAIDs can cause complications in arthritis patients. These can range from minor bleeding in the gastrointestinal tract, to liver or kidney toxicity (poisoning).  In fact, stomach irritation is so common with frequent NSAID use that some doctors also prescribe misoprostol (Cytotec), a drug that protects the stomach lining.  (Misoprostol has its own potential side effects, including nausea, gas, headaches and vomiting; it can cause miscarriage and should never be given to pregnant women).  One prescription product, approved in just the past few years, combines the NSAID diclofenac sodium with misoprostol and is marketed under the name Arthrotec. One of the newest NSAIDs, celecoxib (Celebrex), are reported to be easier on the stomach than older NSAIDs.

• NSAIDs also can interact with other drugs, even over-the-counter preparations.  Antacids, for example, can decrease the absorption of NSAIDs, reducing their pain-fighting effect.  Prescription medicines also can have adverse effects when mixed with NSAIDs.  NSAIDs can augment the action of diuretics, lithium, oral hypoglycemic agents and phenytoin (Dilantin).

• It is extremely important to follow all the label instructions and cautions when taking NSAIDs and to consult with your health care provider if you have any concerns. (See the Arthritis Articles for more information about NSAIDs.)

Non-NSAIDs. Pain relievers that are NOT anti-inflammatories — such as acetaminophen (Tylenol), aspirin plus oxycodone (Percodan), propoxyphene (Darvon), pentazocine (Talwin), meperidine hydrochloride (Demerol) and codeine — can actually cause damage in rheumatoid arthritis patients. If pain is suppressed, but inflammation isn't, movement can worsen the inflammation by releasing more of the enzymes that damage bones and ligaments. 

Glucosamine sulfate. This over-the-counter supplement is found in high concentrations in seashells, from which glucosamine is harvested. While glucosamine has been shown to relieve pain and possibly rebuild cartilage in the joints of osteoarthritis patients, it does not appear to have the same pain-relieving effect for rheumatoid patients. Still, some doctors recommend that rheumatoid patients take a standard dose of glucosamine sulfate — three 500-milligram capsules daily – because it may help prevent some of RA's degenerative effects.

Cortisone. The most powerful anti-inflammatory drugs are the cortisone-type drugs, or corticosteroids. They can be lifesavers when given for asthma attacks or an adrenal crisis.  They may provide complete pain relief when given in high doses on a short-term basis for patients with rheumatoid arthritis flare-ups or when injected into a painful, red-hot, swollen joint. Doctors try to avoid side effects by giving as low a dose as possible and injecting the drugs only at the site of the inflammation.

Comments: Corticosteroids should be considered a last resort treatment. Their side effects from long-term use include osteoporosis (brittle bones), cataracts, glaucoma, high blood pressure, stomach bleeding or irritation, weight gain, frequent infections and worsening of diabetes mellitus. 

Antibiotics.  Doctors sometimes find there is a bacterial component in some kinds of inflammatory arthritis, which can be treated by antibiotics. 

Comments: Because antibiotics can throw off the body's natural balance, it is recommended that patients also take prebiotic supplements, such as insulin, fructoolegosacchrides  (FOS), take probiotics, or eat organic yogurt with various friendly bacterial cultures.

Biologic Response Modifiers (BRMs). These substances target specific parts of the immune system, but leave other parts alone.  For rheumatoid arthritis, the BRM etanercept interferes with a chemical called TNF, which is believed to play a major role in inflammation and joint damage. Another biologic agent, infliximab, blocks TNF through another pathway and has been approved for use in rheumatoid arthritis and Crohn's disease. Oral proteolytic enzymes also are considered biologic response modifiers; they act like biological "vacuum cleaners" to rid the body of harmful proteins that can lodge in the joints.  

Disease-Modifying Anti-Rheumatic Drugs (DMARDs). These agents are used primarily to treat rheumatoid arthritis, but also help people with ankylosing spondylitis, psoriatic arthritis and a few other arthritis-related diseases. DMARDs can slow the advance of disease.  The group includes leflunomide and cyclosporine (originally developed to prevent organ transplant rejection).

Narcotic Drugs - Opioids. When pain is extreme, narcotic drugs derived from opium may be prescribed. For arthritis, the most common narcotics prescribed are propoxyphine (Darvon), codeine (Tylenol #3 or #4) or hydrocodone (Vicodin and Lorcet), although oxycodone (Percodan and Percocet) is being prescribed more often now.  These opioids bring swift pain relief, allowing the patient more activity during the day and better sleep at night. (See the Arthritis Library for more information about opioid drugs.)

Comments: Opioids can have side effects and may lead to dependency, but rarely addiction.  Prescribing them should be done only when more conservative treatment has failed, and a patient understands the risks and rewards involved in their use. Opioids are being used more often in advanced arthritis. (See the Arthritis Library for more information about opioids.)

Mixed Agonists/Antagonists (Synthetic Narcotics). This class of drugs is used at times for arthritis pain.  They include pentazocine (Talwin-NX or Talacen), nalbuphine (Nubain), butorphanol (Stadol or Stadol NS) and buprenorphine (Buprenex). Only pentazocine is available in oral form and likely to be useful on in some cases of advanced arthritis. 

Comments: This group of drugs has what is called a "low ceiling effect," meaning a small dose may be helpful, but more can cause complications. They also cannot be mixed with strong natural narcotic drugs.

Ankylosing Spondylitis

Early diagnosis and treatment of this condition is critical to controlling pain and stiffness, and perhaps plays a part in preventing the bones in the neck and back from fusing. In women, ankylosing spondylitis (AS), or spinal arthritis, often is mild and difficult to diagnose.  Treatment is tailored to the individual.

Disease-Modifying Anti-Rheumatic Drugs (DMARDs), or Slow-Acting Anti-Rheumatic Drugs (SAARDs).  While these agents typically are used more frequently to treat other forms of arthritis, they can provide relief.  However, they may take several months to become effective.  The group includes leflunomide, sulfasalazine and cyclosporine (originally developed to prevent organ transplant rejection).  

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). More than 30 drugs are classified as NSAIDs, which can help relieve pain and stiffness, but do not affect the advance of ankylosing spondylitis.  NSAIDs include over-the-counter drugs such as ibuprofen.  Each NSAID has a slightly different chemical structure, is metabolized differently, and seems to work differently among individual patients. For severe AS pain, the NSAID Ketorolac (Torodol) can be given as an injection for speedy, although brief, pain relief.

Comments:

•  Long-term use of NSAIDs can cause complications in AS patients. These can range from minor bleeding in the gastrointestinal tract, to liver or kidney toxicity (poisoning).  In fact, stomach irritation is so common with frequent NSAID use that some doctors also prescribe misoprostol (Cytotec), a drug that protects the stomach lining.  (Misoprostol has its own potential side effects, including nausea, gas, headaches and vomiting; it can cause miscarriage and should never be given to pregnant women).  One prescription product, approved in just the past few years, combines the NSAID diclofenac sodium with misoprostol and is marketed under the name Arthrotec. One of the newest NSAIDs, celecoxib (Celebrex), is reported to be easier on the stomach than older NSAIDs.

• NSAIDs also can interact with other drugs, even over-the-counter preparations.  Antacids, for instance, can decrease the absorption of NSAIDs, reducing their pain-fighting effect.  Prescription medicines also can have adverse effects when mixed with NSAIDs.  NSAIDs can augment the action of diuretics, lithium, oral hypoglycemic agents and phenytoin (Dilantin).

• It is extremely important to follow all the label instructions and cautions when taking NSAIDs and to consult with your health care provider if you have any concerns. (See the Arthritis Library for more information about NSAIDs.)

Oral Tramadol (Ultram). Available for moderate to severe pain.

Comments: When introduced to the United States in 1966, the U.S. Food and Drug Administration classified tramadol as a non-narcotic drug. However, some cases of addiction have been reported. Tramadol also has been linked to seizures in susceptible individuals, especially when the drug is given at high doses. The risk of seizure is higher in patients who are also taking antidepressant drugs such as Norpramine or Sinequen).  Caution also has been advised with well-known anti-depressants fluoxetine hydrochloride (Prozac), sertraline hydrochloride (Zoloft) and paroxetine (Paxil).

Narcotic Drugs.  When pain is extreme, narcotic drugs, derived from opium, may be prescribed. For arthritis, the most common narcotics prescribed are propoxyphine (Darvon), codeine (Tylenol #3 or #4) or hydrocodone (Vicodin and Lorcet), although oxycodone (Percodan and Percocet) is being prescribed more often now.  These narcotic drugs bring swift pain relief, allowing the patient more activity during the day and better sleep at night. They are being used more often in inflammatory forms of the disease such as ankylosing spondylitis.

Comments: Opioids can have side effects and may lead to dependency, but rarely addiction.  Prescribing them should be done only when more conservative treatment has failed, and a patient understands the risks and rewards involved in their use. Opioids are being used more often in advanced arthritis. (See the Arthritis Library for more information about opioids.)

Gout

To control the pain and inflammation of acute gout episodes, doctors usually prescribe nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine or corticosteroids.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). These are among the most common treatments for gout pain.  Purchased over-the-counter or by prescription, NSAIDs — such as aspirin, ibuprofen (Advil or Motrin) and diclofenac — act quickly to relieve pain. There are more than 30 drugs classified as NSAIDs and each has a slightly different chemical structure, is metabolized differently and seems to work differently among patients. (Other drugs, such as methotrexate, chloroquine, pencillamine and gold salts, work through the immune system and have some anti-inflammatory effects.)

Comments:

• Aspirin is probably the least expensive NSAID available. Its active ingredient is synthesized from salicin, a natural substance found in willow bark and other plants. Americans take more than 30 billion aspirin tablets a year at a cost of $1 billion. However, aspirin has multiple side effects – so many, in fact, that the drug probably would not receive modern-day U.S. Food and Drug Administration approval.  While low doses of aspirin appear to help prevent heart attacks and may help prevent colon cancer and Alzheimer's Disease, Aspirin can cause gastrointestinal problems and trigger life-threatening allergic reactions in some people. (See the Arthritis Library for more information about aspirin.)

•  Long-term use of NSAIDs can cause complications in arthritis patients. These can range from minor bleeding in the gastrointestinal tract, to liver or kidney toxicity (poisoning).  In fact, stomach irritation is so common with frequent NSAID use that some doctors also prescribe misoprostol (Cytotec), a drug that protects the stomach lining.  (Misoprostol has its own potential side effects, including nausea, gas, headaches and vomiting; it can cause miscarriage and should never be given to pregnant women).  One prescription product, approved in just the past few years, combines the NSAID diclofenac sodium with misoprostol and is marketed under the name Arthrotec. One of the newest NSAIDs, celecoxib (Celebrex), is reported to be easier on the stomach than older NSAIDs.

• NSAIDs also can interact with other drugs, even over-the-counter preparations.  Antacids, for example, can decrease the absorption of NSAIDs, reducing their pain-fighting effect.  Prescription medicines also can have adverse effects when mixed with NSAIDs.  NSAIDs can augment the action of diuretics, lithium, oral hypoglycemic agents and phenytoin (Dilantin).

• It is extremely important to follow all the label instructions and cautions when taking NSAIDs and to consult with your health care provider if you have any concerns. (See the Arthritis Library for more information about NSAIDs.)

Colchicine. Once a traditional gout treatment, this agent often is replaced by NSAIDs. Colchicine usually is given orally, but can be given intravenously if it upsets the stomach.

Comments: This drug often causes diarrhea and can prompt more serious side effects including damage to bone marrow.

Corticosteroids. These potent drugs, such as Prednisone, act quickly to relieve pain and swelling. If only one of two joints is affected by gout, doctors sometimes inject a corticosteroid crystal solution through the same needle used to remove fluid from the joint.

Comments: Long-term corticosteroids use can cause side effects, including osteoporosis (brittle bones), cataracts, glaucoma, high blood pressure, stomach bleeding or irritation, weight gain, frequent infections and worsening of diabetes mellitus.

Other Gout Drugs. Once the pain and swelling is controlled,  further treatment of gout depends on finding out the cause of the body's overabundance of uric acid. If the body produces too much uric acid, doctors typically prescribe a drug call allopurinol.  If the body cannot excrete uric acid well, probenecid or sulfinpyrazone is prescribed.

Systemic Lupus Erythematosus (SLE)

The more severe the disease, the more aggressive the treatment.  Pain relievers and nonsteroidal anti-inflammatory drugs (NSAIDs) usually are effective for fever, stiffness, headaches and rash. More aggressive treatment is needed if there is serious disease progression, evidenced by such developments as hemolytic anemia, major involvement of the heart or lungs, significant kidney damage or severe central nervous system symptoms.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs).  These are the most common treatments for SLE pain.  Purchased over-the-counter or by prescription, NSAIDs – such as aspirin, ibuprofen (Advil or Motrin) and diclofenac — act quickly to relieve pain. More than 30 drugs are classified as NSAIDs, and each has a slightly different chemical structure, is metabolized differently and seems to work differently among patients.

Comments:

•  Long-term use of NSAIDs can cause complications in SLE patients. These can range from minor bleeding in the gastrointestinal tract, to liver or kidney toxicity (poisoning).  In fact, stomach irritation is so common with frequent NSAID use that some doctors also prescribe misoprostol (Cytotec), a drug that protects the stomach lining.  (Misoprostol has its own potential side effects, including nausea, gas, headaches and vomiting; it can cause miscarriage and should never be given to pregnant women).  One prescription product, approved in just the past few years, combines the NSAID diclofenac sodium with misoprostol and is marketed under the name Arthrotec. One of the newest NSAIDs, celecoxib (Celebrex), is reported to be easier on the stomach than older NSAIDs. Also a gel containing ibuprofen can be applied to sore joints and may have less impact on the gastrointestinal tract.

• Experimental agents are being developed that combine nitric oxide with NSAIDs. Nitric oxide increases blood flow in the mucous lining and secretions of mucus and bicarbonate, and may ease stomach problems.

• NSAIDs can interact with other drugs, even over-the-counter preparations.  Antacids, for instance, can decrease the absorption of NSAIDs, reducing their pain-fighting effect.  Prescription medicines also can have adverse effects when mixed with NSAIDs.  NSAIDs can augment the action of diuretics, lithium, oral hypoglycemic agents and phenytoin (Dilantin).

• It is extremely important to follow all the label instructions and cautions when taking NSAIDs and to consult with your health care provider if you have any concerns.

Steroid Creams. These creams often are used for skin rashes, although a non-steroid cream derived from Vitamin A called Tegison has helped some patients. Always protect your skin from the sun by using sunblock creams and wearing hats and tightly woven fabrics.

Antimalarial Drugs. These drugs are most often prescribed if the main symptoms are skin and joint pain. The most common drugs are hydroxychloroquine (Plaquenil), chloroquine (Aralen) and quinacrine (Atabrine).  Researchers aren't sure why these drugs work; they may inhibit the immune response and or somehow interfere with inflammation. Antimalarials may also be used in combination with other anti-SLE drugs, including immunosuppressants and corticosteroids. Hydroxychloroquine may reduce the risk of blood clots as well as reduce cholesterol levels, which sometimes become elevated in patients who must take corticosteroids.

Comments. Side effects of antimalarials can include skin rash, change in skin color, gastrointestinal problems, headache, hair loss, muscle aches and damage to the retina (although the latter is very uncommon when low doses are used).

Corticosteroids. Severe SLE is treated with corticosteroids, also called steroids, which suppress the inflammatory process, and help relieve many of the complications and symptoms, including anemia and kidney involvement. Steroids include prednisone (Deltasone, Orasone), methylprednisolone (Medrol, Solumedrol), hydrocortisone, and dexamethasone (Decadron). Your doctor will tailor your prescriptions to the severity and location of your disease. The drugs may be administered orally or as an injection. An intravenous administration of methylprednisolone using "pulse" therapy for three days is proving useful for flare-ups in the joints. 

Comments: Long-term use of steroids can cause weight gain, high blood pressure, acne, and susceptibility to infection, insomnia, and bone damage. To counter bone loss, the American College of Rheumatology recommends that patients take 1,500 mg of calcium a day; vitamin D supplements may also be warranted.

Immunosuppressant Drugs. In severe, active SLE cases, particularly when kidney or central nervous system involvement or acute blood vessel inflammation is present, drugs known as immunosuppressants often are used, either alone or with corticosteroids. These drugs suppress the immune system. The most common immunosuppressants are azathioprine (Imuran), methotrexate (Rheumatrex), and cyclophosphamide (Cytoxan). Other drugs commonly used include chlorambucil (Leukeran), nitrogen mustard (Mustargen), and cyclosporine (Sandimmune). Mycophenolate mofetil is a promising new immunosuppressant, which may help patients who do not respond to other immunosuppressants. About a third of patients take immunosuppressants at some point in the course of the disease, most commonly for serious kidney problems and also for neurologic and arthritic symptoms and when flares are widespread.

Comments: These drugs can cause stomach and intestinal distress, skin rashes, mouth sores and hair loss.  If the immune system is suppressed too much, serious side effects – anemia, menstrual irregularities, possible infertility, shingles, and liver and bladder toxicity – can occur.

Hormones. SLE patients typically have abnormally low levels of the hormone dehydroepiandrosterone (DHEA).  Some studies show that taking DHEA may be modestly effective in treating SLE, especially in helping to prevent the bone loss that can accompany steroids.

Comments: Side effects include acne and hair growth.