If you suffer from osteoarthritis, then medicines to provide pain relief and reduce inflammation will likely form part of your treatment plan. Much of osteoarthritis treatment and prevention is physical or biomechanical — aimed at reducing stress on joints or improving strength and stopping progression. This is often achieved by losing weight, if you are overweight, and with strength and flexibility exercises. However, pain relief is no less important, and this is where medicines can help people with osteoarthritis.
Paracetamol is often the first medicine tried for the pain of osteoarthritis, however, recent guidelines do not recommend it as a first option, and show only low-level pain relief for osteoarthritis – and in knee osteoarthritis only the same level of pain relief as dummy treatment (placebo). A 2016 analysis of paracetamol to treat knee and hip osteoarthritis did not recommend it and found it to be clinically ineffective.
Although paracetamol is available without a prescription, this does not mean it is without side effects and concerns are increasing around its safety in high doses when used regularly for pain relief, and when it is taken along with NSAIDs (non-steroidal anti-inflammatory drugs, such as ibuprofen).
You should not take more than 8 tablets (4 g) per 24 hours without consulting your doctor, as liver damage may occur in amounts greater than this.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (known for short as NSAIDs) are increasingly replacing paracetamol as the first recommendation for medicines to help with osteoarthritis pain and inflammation symptoms. Many people with chronic arthritis are helped by taking one of the NSAIDs.
There are 2 types of NSAIDs: non-selective and selective (also known as coxibs or cox-2 inhibitors). Some NSAIDs such as ibuprofen (Nurofen) or diclofenac (Voltaren) can be purchased over the counter from a pharmacy, and others are prescription only, such as naproxen (e.g. Naprosyn).
Selective NSAIDs (coxibs) are only available with a prescription
As their name implies, NSAIDs reduce inflammation of the joints, without using steroids. Taking these medicines can reduce the pain of arthritis, reduce joint stiffness and improve mobility. However, NSAIDs do not cure arthritis or have a long-term effect after you stop taking them.
Common non-selective NSAIDs include ibuprofen (e.g. Advil, Brufen, Nurofen), naproxen (e.g. Naprosyn), diclofenac (e.g. Clonac, Voltaren), piroxicam (e.g. Feldene), ketoprofen (e.g. Orudis SR) and indomethacin (e.g. Indocid). As mentioned some are available from the pharmacy and some are available only on prescription.
There doesn’t seem to be any major difference between NSAIDs in terms of their effectiveness, but some people get more relief from one NSAID than another, so you may need to try a couple of different NSAIDs to find one that works for you. Your doctor will be able to advise you on whether NSAIDs are suitable for you and which one to try.
Side-effects of NSAIDs
Unfortunately, non-selective NSAIDs have the potential to cause gastrointestinal side-effects such as stomach ulcers and bleeding, which limits their use for those people susceptible to stomach problems. NSAIDs should be taken with food to lessen any risks of side effects.
All NSAIDs should also be used at the lowest possible dose that controls symptoms for the shortest possible time.
If you develop any symptoms such as bloody or black stools or vomit blood, or have severe stomach pains you should get immediate medical attention.
Taking NSAIDs may also put people at increased risk of heart attack and stroke, especially people already at higher risk. NSAIDs can also make heart failure and kidney failure worse. This is true for both types of NSAIDs – selective and non-selective.
If you take ‘blood-thinning’ anti-coagulant drugs, such as warfarin, you should check with your doctor before taking NSAIDs, as the drugs in combination may increase your risk of bleeding.
Selective NSAIDs (Coxibs)
Selective NSAIDs, also called COX-2 specific inhibitors or coxibs, are a more recent class of medicine which appears to be just as effective in relieving pain and inflammation as the older NSAIDs, but with fewer side-effects.
Celecoxib (including brand names Celebrex, Celecoxib Sandoz), etoricoxib (brand name Arcoxia) and meloxicam (Mobic, Movalis) are the coxibs available in Australia. They are available only with a prescription.
Side-effects of coxibs
Coxibs are believed to cause fewer gastrointestinal side effects and may be suitable for some people who cannot take the older, non-selective NSAIDs.
However, all NSAIDs, including these newer selective types (coxibs), may increase the risk of heart attack and stroke. As mentioned above this risk appears to be higher in people who are already at high risk of heart attack or stroke (e.g. those with a history of heart attack or stroke, smokers, people who are overweight, those with high cholesterol, high blood pressure, or diabetes). NSAIDS can also increase blood pressure and make heart failure and kidney failure worse.
You can discuss the risks and benefits of treatment with NSAIDs with your doctor, who will be able to tell you whether or not they are suitable for you.
Topical NSAIDs (which are rubbed into the skin) are available as creams or gels and can help ease pain around joints, such as in osteoarthritis of the knee or hand. Their effect is limited to the area they are applied to.
Topical NSAIDs include piroxicam (Feldene Gel), ibuprofen (Nurofen Gel), and diclofenac (Voltaren Emulgel, Dencorub Anti-inflammatory Gel). They are available over-the-counter from pharmacies.
Even though topical NSAIDs are applied to the skin, they may still cause side-effects, however, because the amount used is usually lower, side-effects are reduced compared with oral NSAIDs. Some people experience the side-effect of a skin rash. If you get a skin rash while using a topical NSAID, stop using it and see your doctor.
Another potential side-effect of some topical NSAIDs is photosensitivity – when your skin becomes sensitive to light and you experience a rash or sunburn when you wouldn’t normally expect to.
Other analgesics (painkillers)
Simple analgesics (painkillers) such as NSAIDs or paracetamol should be tried before combination analgesics such as paracetamol plus codeine or NSAID plus codeine. Osteoarthritis is more common in elderly people than younger people, and it is normally recommended that the elderly avoid products containing codeine as it affects the central nervous system (CNS) and elderly people may be more susceptible to CNS effects such as drowsiness and sedation. In addition, medicines such as codeine can cause constipation.
Tramadol (e.g. Tramal and other brands) is a prescription painkilling medicine that is classified as an opioid (morphine-like) agent, but that also has some additional actions. It may be helpful in arthritis pain not relieved by NSAIDs (non-steroidal anti-inflammatory drugs), however tramadol may cause side-effects, such as sedation and nausea (feeling sick) that limit its use. Tramadol may also be addictive in some cases.
Tapentadol (brand name Palexia) is another opioid with similar actions to tramadol. It is a strong pain reliever and like other opioid pain relievers may be addictive. Tapentadol has not been used in Australia for as long as tramadol. It is currently only available for ongoing severe disabling pain that isn’t relieved by non-opioid medicines. Side effects include drowsiness and dizziness and constipation.
Corticosteroids are a type of steroid naturally made by the adrenal glands. They work by acting against inflammation and in higher doses suppress the immune system. Corticosteroids can be taken as tablets or as injections into the joint, which is more common in osteoarthritis. Corticosteroid injections can provide short-term pain relief from arthritis. Your doctor will advise whether this is recommended for you.
Frequent injections of corticosteroids may lead to damage to joint structures, so this treatment is usually limited to 2-3 times per year. You may be advised to avoid using the joint too much for 24-48 hours after the injection to ensure the beneficial effects last as long as possible.
Hyaluronan (hyaluronic acid) is a natural component of the synovial fluid in a joint and plays a critical role in normal joint functions, such as lubrication and keeping down inflammation. In a joint with osteoarthritis, the hyaluronan is affected and can’t carry out these functions so well. Injecting hyaluronan into a joint to supplement the natural hyaluronic acid theoretically helps with lubrication of the joint and shock absorption, however, results concerning its effectiveness are inconsistent.
Hylan (e.g. brand name Synvisc) is a hyaluronan-based product available for the treatment of pain associated with osteoarthritis of the knee. It is given as a course of 3 injections over 3 weeks.
Durolane is a brand of hyaluronic acid used for injection to treat osteoarthritis of the knee. One injection is given per treatment course.
Sodium hyaluronate (e.g. Fermathron) is a similar product also available for osteoarthritis of the knee joint. It is given by injection into the affected joint once weekly for no more than 5 weeks.
These products are not currently subsidised on the PBS so the treatment may be expensive. Trials have shown inconsistent evidence of benefit.
Side effects of these injections include short-lived pain and swelling around the injection site.