NSAIDs (Nonsteroidal Anti-inflammatory Drugs)
Nonsteroidal anti-infflammatory drugs, or NSAIDs, are the most commonly used drug treatments for OA pain and stiffness. NSAIDs include (but are not limited to) aspirin, ibuprofen, meloxicam, naproxen and celecoxib. They are available over-the-counter or by prescription and may be taken orally or applied topically to the skin in a cream, lotion or gel form. Topical NSAIDs cause less side effects because they do not entire the bloodstream as much as NSAIDs taken as pills do.
Here are the ACR’s recommendations regarding drug therapy for OA:
- Patients with hand OA should be treated with either topical or oral NSAIDs, topical capsaicin, tramadol, or celecoxib (a COX-2 selective inhibitor).
- Patients with knee OA should be treated with intermittent dosing of OTC acetaminophen, OTC NSAIDs, and/ or OTC nutritional supplements. For those who fail to get symptom relief from any of these treatments, either topical or oral prescription NSAIDs, topical capsaicin, or tramadol should be used.
- NSAID recommendations for patients with hip OA are similar to those for patients with knee OA except that no recommendations were made for topical NSAIDs due to a lack of clinical data on their benefit or safety at the time the guidelines were published.
The ACR believes that most OA patients benefit from treatment with NSAIDs and that the positive consequences far outweigh potential side effects for most people. Your doctor may change your NSAID dose depending on how severe your symptoms are. Whether or not your doctor recommends that you use NSAIDs continuously will depend on the severity of your symptoms and how often you have them, other diseases you may have and your personal preferences.
Common NSAIDs you might take for your OA pain:
- Ibuprofen (Advil®, Motrin®)
- Naproxen sodium (Aleve®)
- Celecoxib (Celebrex®)
- Diclofenac sodium (Voltaren®)
- Indomethacin (Indocin®)
- Ketoprofen (Actron®, Orudis®)
- Piroxicam (Feldene®)
- Meloxicam (Mobic®)
Learn more about NSAIDs.
Acetaminophen may be used for mild to moderate OA pain. Some people with OA control their joint pain or stiffness with an NSAID, corticosteroid injections or non-drug therapies, so you may not need acetaminophen at all or only once in a while.
Acetaminophen is sold under the brand name Tylenol® and is typically used to treat pain and reduce fever. It is sold over the counter, but your doctor may also write you a prescription for acetaminophen. It is taken orally. It is generally safe to use for minor fares of pain and typically does not have side effects, though large amounts taken over a long period of time can potentially cause liver damage. The most common side effects, though rare, are rash, nausea, and headache.
The ACR’s recommendations regarding acetaminophen for OA are as follows:
- For patients with OA of the hand, ACR does not recommend for or against acetaminophen.
- For patients with OA of the knee, ACR recommends that patients who do not get adequate pain relief with intermittent dosing of OTC acetaminophen, OTC NSAIDs, and/or OTC nutritional supplements should be treated with consistent, higher dosing of acetaminophen, prescription strength oral or topical
- For patients with OA of the hip, ACR recommendations are similar to those for patients with knee OA regarding acetaminophen.
Learn more about acetaminophen.
In 2010, the FDA approved the use of the oral medication duloxetine (Cymbalta®), a type of drug known as a selective SNRI (serotonin and norepinephrine reuptake inhibitor), for chronic musculoskeletal pain, including OA. It was first approved by the FDA in 2004 as a treatment for depression, and is also used for other health concerns, including other mood disorders, nerve pain and fibromyalgia.
It was approved for use in OA based on two clinical trials that showed it was associated with significant pain reduction and improved function in patients with pain due to knee OA. The approved dose for chronic musculoskeletal pain is a 60mg capsule taken once a day, swallowed whole; it does not have to be timed with meals but doing so may help alleviate nausea, which can be a side effect with this medicine.
The ACR’s recommendation regarding duloxetine for OA is as follows:
- For patients with OA of the hand, knee or hip, ACR has no recommendations regarding the use of duloxetine due to the lack of data from randomized clinical trials at the time of publication in 2012. The ACR is reviewing new data that have been published since 2012 for their upcoming updated treatment guidelines.
Learn more about duloxetine.
Glucocorticoids (Steroid Injections)
Glucocorticoids are medicines used to reduce inflammation. They may also be called corticosteroids or even “steroids” for short. If you have OA, you’re more likely to get a steroid injection directly into your painful joint, not steroids that are taken orally. OA affects particular, individual joints, not your whole body. A glucocorticoid shot can help to ease pain in a specific joint that’s affected by OA.
Current formulations of injectable glucocorticoids include short-acting agents (methylprednisolone or Medrol) and longer-acting agents (triamcinolone) which are combined in a single injection along with an anesthetic agent (lidocaine). A new formulation of triamcinolone has recently been approved by the FDA for articular injection.
Zilretta® is an extended-release formulation of triamcinolone acetonide (a glucocorticoid) incorporated into microspheres for injection into the knee joint. This formulation releases the drug slowly into the knee joint fluid for up to 12 weeks. There is no evidence of effects on plasma glucose concentrations, a known complication of articular steroid injections. Patients receiving this drug report sustained pain relief following single injection (up to and beyond the 12 week study period), a treatment response not typically seen from other steroid injections.
Learn more about glucocorticoids.
Intra-Articular Hyaluronate (Hyaluronic Acid Injections)
Hyaluronic acid (HA) is a natural, gel-like, lubricating substance that occurs in your joint fluid and cartilage, acting as a shock absorber and lubricant. However, the acid appears to break down in people with osteoarthritis.
Injections of hyaluronic acid directly into the knee joint are selectively used in the treatment of OA. Most people who try these injections do so after treatments like physical therapy, exercise, and injections with steroids don’t give them enough symptom relief.
HA injections are FDA approved for use in the knee only; however, some physicians will also use them in other joints with OA, such as the hip or ankle. For some patients, these injections provide pain relief by providing some cushioning in the knee. However, the relief does not last long-term and some, but not all, studies suggest that any relief a patient experiences with these injections is the result of the placebo effect, in which the patient feels relief only because he or she expects the treatment to work.
The ACR’s recommendation for HA injections is as follows:
- For patients with OA of the knee, ACR has no recommendation regarding HA injections because of the lack of data from randomized clinical trials on either benefit or safety at the time of publication.
- For patients with OA of the hip, no recommendations were made for the use of hyaluronic acid injections because of the lack of data from randomized clinical trials on either benefit or safety at the time of publication.
- For patients with OA of the hand, ACR recommends not using either intraarticular corticosteroids or HA injections and, furthermore, provided no recommendation on the choice between corticosteroids and hyaluronates, if a provider decides to give an injection.
Learn more about hyaluronic acid injections.
Sold under the brand name Ultram®, Ultracet and Ultram® ER (extended release), among others, tramadol is an opioid pain medicine used to treat moderate to moderately severe pain. It is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. It is sometimes prescribed to treat OA pain, particularly for patients with severe pain for whom NSAIDs and acetaminophen do not provide symptom relief. However, more recent data suggest that tramadol does not offer any more pain relief than NSAIDs.
Tramadol can help to decrease OA pain intensity, relieve symptoms, and improve function. The regular tablet is taken with or without food every four to six hours as needed. The extended-release tablet and extended-release capsule should be taken once a day. Your doctor may start you on a low dose of tramadol and gradually increase the amount of medication you take.
BE AWARE: Tramadol and other opioids are not routinely recommended to manage OA pain. There are many options to manage OA pain that are more effective and far less risky for your health. These drugs carry serious risks of dependence or even abuse. Opioid addiction and abuse are a significant problem in the United States. As a result, people taking opioids must be carefully monitored. Talk with your physician about the risks of taking tramadol or any other opioid for pain, even if you only think you will take these drugs on an occasional basis. Many people become dependent on or addicted to opioids even with short-term use. The potential pain-relieving benefits of taking an opioid to manage chronic pain really do not outweigh the risks for most people.
The ACR’s recommendations for tramadol are as follows:
- For patients with hand OA who fail to obtain adequate pain relief with intermittent dosing of OTC acetaminophen, OTC NSAIDs, and/or OTC nutritional supplements (e.g., chondroitin sulfate, glucosamine), ACR recommends either topical or oral NSAIDs, topical capsaicin, or tramadol.
- For patients with knee OA who fail to obtain adequate pain relief with intermittent dosing of OTC acetaminophen, OTC NSAIDs, and/or OTC nutritional supplements, ACR recommends acetaminophen, oral or topical NSAIDs, tramadol, or intraarticular corticosteroid injections.
- For patients with hip OA who fail to adequate pain relief with intermittent dosing of OTC acetaminophen, OTC NSAIDs, and/or OTC nutritional supplements, ACR recommends acetaminophen, oral NSAIDs or tramadol.
Learn more about tramadol.