Medication for Osteoarthritis
How osteoarthritis is treated depends on how severe the pain is. Many people find that they can manage their osteoarthritis with a combination of over-the-counter pain killers and self management but if the pain is severe your doctor may prescribe a range of other pain relief including capsaicin cream, stronger painkillers, steroid injections, transcutaneous electrical nerve stimulation (TENS) or surgery including joint replacement.
The most widely-used painkiller is paracetamol. Paracetamol is safe in doses up to 4 grams daily and rarely causes side-effects. One paracetamol tablet will contain 500mg of paracetamol – up to eight tablets can be taken in any 24-hour period, but these must be spaced out over the day, with one or two tablets taken at each dose and a gap of at least four hours between doses. Taking more than this or consuming large amounts of alcohol with paracetamol can lead to permanent liver damage. Paracetamol is often used in combination with other medicines such as NSAIDs and opiates.
Capsaicin cream for osteoarthritis
Capsaicin cream is made from the pepper plant (capsicum) and is an effective and very well-tolerated painkiller. You’ll need to apply it three times each day for it to be effective. It’s particularly useful for knee and hand osteoarthritis. It’s only available on prescription. Most people feel a warming or burning sensation when they first use capsaicin, but this generally wears off after several days. The pain-relieving effect starts after several days of regular use. You should try it for at least two weeks before deciding if it has helped.
Stronger pain killers
Non-steroidal anti-inflammatory drugs (NSAIDs, anti-inflammatories)
Anti-inflammatories work in a different way to paracetamol and are able to reduce both pain and inflammation. You can expect to start getting pain relief with the first dose of an anti-inflammatory, but it may take up to two weeks for there to be any effect on inflammation.
There are many different anti-inflammatories, but the most widely-used are ibuprofen, naproxen and diclofenac. Celecoxib and etoricoxib are also anti-inflammatories but work in a slightly different way to the others.
The dose is different depending on which anti-inflammatory you are prescribed. Your doctor will discuss with you what type of NSAID you should take and the benefits and risks associated with each of them. Different anti-inflammatories are available as tablets or capsules, and some can be used topically – they come as creams, gels, or sprays that are applied to the affected joints. If you have lots of joints affected by arthritis, taking anti-inflammatory tablets or capsules will probably be more effective, but if only a couple of joints are a problem then a topical anti-inflammatory may be suitable. You should not use topical and oral anti-inflammatories together.
While most people can take anti-inflammatories without any problem, they may not be suitable if you have a history of heart, stomach, or kidney problems. If you are taking low-dose aspirin, discuss with your GP whether you should use an NSAID. Anti-inflammatories can interact with other medicines so you should always check with your doctor, pharmacist, or nurse before using anti-inflammatories if you are taking any other medicines. To avoid causing serious side-effects, anti-inflammatories should be taken in the lowest effective dose for the shortest period of time possible.
Using anti-inflammatories can increase the risk of serious stomach problems, such as bleeding from the gut. For this reason, they must always be taken with or just after food. If you are likely to be taking anti-inflammatories for a long time you will probably be prescribed another medicine to protect your stomach. If you develop any new symptoms like indigestion or dark stools (poo), or an existing stomach problem gets worse while taking anti-inflammatories, you should contact your doctor for advice. Although these problems are serious they do not happen very often. Research has shown that if two to three thousand people take anti-inflammatories, one of these people will have a serious stomach bleed. Medicines like etoricoxib and celecoxib are less likely to cause these problems.
Anti-inflammatories are also known to cause problems with blood pressure, and can also increase the risk of heart attacks, stroke and kidney problems if they are taken regularly for a long time. Your doctor may want you to have blood tests to keep an eye on your kidney function and will also check your blood pressure regularly.
There are two main types of opioid; weak opioids include codeine, dihydrocodeine and tramadol; the strong opioids include morphine and fentanyl. These can all be used alongside paracetamol and anti-inflammatories, and combination products containing paracetamol and codeine (co-codamol) or dihydrocodeine (co-dydramol) are available. These are usually taken by mouth, though patches containing fentanyl or buprenorphine are available and might be used if patients need regular opioids to manage their pain.
Unlike anti-inflammatories, which work in the joints themselves, opioids work in the central nervous system. Doses of these medicines are usually increased in a step-wise manner to get a balance between pain reduction and unwanted side-effects. The common side-effects of this class of medicines are constipation, nausea and drowsiness. High fibre diet and laxatives may be useful if the medicines are helping pain but causing constipation. Drowsiness may be helpful if the medications are used at night in people with sleep disturbance due to pain, but care must be taken during daytime activities such as driving. The term “opioids” is often associated with fears of addiction. However many patients use these medications for chronic pain without becoming addicted.
Combinations of the above drugs may be useful in some patients since the drugs work in different ways, for example, combining an NSAID and an opioid analgesic. For certain types of pain, antidepressants or antiepileptic medicines may sometimes be used – research has shown that these medicines can be effective for certain types of pain in people who do not have depression or epilepsy.
Steroid injections for osteoarthritis
Some steroids occur naturally in your body. Man-made steroids act like natural steroids to reduce inflammation. They can be given in tablet form or as an injection. A steroid mixture can be injected into or around an inflamed joint to ease your symptoms. It’s called a local injection because it acts in a particular area.
Steroids reduce inflammation and sometimes are used for osteoarthritis when your joints are swollen.
Your GP, rheumatologist, orthopaedic surgeon, rheumatology nurse specialist or physiotherapist will choose the most appropriate steroid mixture and dose. Most injections are quick and easy to perform. If you have an injection into a joint, you should rest it as much as possible for the first 1–2 days. If this isn’t possible, you should at least avoid strenuous exercise for the first couple of days. If you’re having a course of physiotherapy, the physiotherapist may be keen to give more intensive mobilisation treatment after the injection, while your joint is less painful. If the injection is very helpful, and other treatments are either unsuitable or less effective for you, it may be repeated if necessary. Short-acting soluble steroids can give relief within hours and should last for at least a week. The longer acting, less soluble steroids may take around a week to become effective but can ease your symptoms for 2 months or longer. Sometimes you’ll be given a local anaesthetic with the steroid to reduce the discomfort of the injection, although it won’t have an effect on the inflammation. If this is the case, your pain should ease within minutes but it’ll usually wear off within half an hour unless the anaesthetic selected is long acting. You can take paracetamol if your joint is painful.
For more information on local steroid injections see:
Transcutaneous electrical nerve stimulation (TENS)
Transcutaneous electrical nerve stimulation (TENS) can help to ease pain, although research evidence on its effectiveness is mixed. A TENS machine is a small electronic device that sends pulses to your nerve endings via pads placed on your skin. It produces a tingling sensation and is thought to alter pain messages sent to your brain.
TENS machines are available from pharmacies and other major stores, but your physiotherapist may be able to loan you one to try before you decide whether to buy one.
Surgery for osteoarthritis
Surgery may be recommended if your pain is very severe or you have mobility problems. Many thousands of hip and knee replacements are performed each year for osteoarthritis, and other joint replacements are becoming increasingly common. Surgery can be very good for easing pain when other treatments haven’t given enough relief.
To find out more information click here to look at our page on ‘Surgery’
Glucosamine sulphate and glucosamine hydrochloride are nutritional supplements. The evidence that glucosamine can delay the breakdown of cartilage or repair damaged cartilage is weak.