Given the widespread occurrence of osteoarthritis and polypharmacy considerations, these authors emphasize a heightened awareness of OTC medications and assess the pros and cons of various prescription options for treating OA.

Osteoarthritis (OA) is the most common form of the chronic inflammatory joint processes and occurs in 25 percent of the adult population. Although the vast majority of individuals have some symptoms by the age of 40, major symptoms and disabilities may not occur until the age of 60.

Indeed, OA is one of the most common forms of degenerative diseases we face as we get older. Osteoarthritis is a progressive breakdown of articular cartilage that lines the joint surface as dense, smooth-surfaced bone forms at the base of the cartilage and marginal osteophytes develop.

While some may perceive OA as an inflammatory condition, it is actually an irritation, due to a breakdown of articular cartilage, that results in an inflammatory condition with variable synovial inflammation. Factors associated with the development of OA include: joint trauma, aging, obesity, overuse, joint weakness, congenital musculoskeletal metabolic disorders, endocrine disorders and crystalline deposit disease.

The clinical presentation of OA involves an insidious onset of joint pain. Patients often associate pain with a limitation of movement and joint stiffness. Crepitus and occasional joint effusions are characteristic signs. Joint deformity and        the formation of bony cysts can occur in later stages. The joints most often affected are the distal and proximal interphalangeal joints, the metacarpal joints, knees, hips and the cervical and lumbarsacral spine.

Much of OA therapy is physical or biomechanical in nature. Our goals as practitioners are to reduce stress on joints and improve strength. We can accomplish this through weight loss and flexibility movement. Indeed, an active exercise program to strengthen muscles around the joint may prevent the development of OA. However, pain relief is just as important. Determining the best choice(s) for treatment is dependent on a variety of factors. Accordingly, let us take a closer look at current medications for treating osteoarthritis pain.

Why It Is Essential To Stay On Top Of OTC Analgesics And NSAIDs
Given the multitude of over-the-counter (OTC) options for OA, many patients may initiate therapy with these agents prior to an office visit. One would usually take OTC therapies for milder symptoms and then on an as needed basis. However, given that older patients may be taking medications for other conditions as well, it is important to obtain a full list of current prescription and non-prescription medications during the patient history.

Given that older patients may be taking medications for other conditions as well, it is important to obtain a full list of current prescription and non-prescription medications during the patient history.

Clinicians should be aware of the efficacy, as well as the possible side effects, of OTC medications. Not only will patients ask for recommendations on these drugs, it is important to be cognizant of a patient’s current medications in order to reduce the risk of possible drug-to-drug interactions.
Simple analgesics are generally the first line of therapy. Drugs such as acetaminophen (Tylenol, Johnson and Johnson) are common choices for mild to moderate OA. In regard to using these medications for OA, it has been suggested that taking these medications on a regular basis, and not as needed, can help achieve the best results.

Given that inflammation can occur as a result of the irritation of the joint due to a breakdown of articular cartilage, non-steroidal antiinflammatory drugs (NSAIDs) can provide results in treating OA. Over-the-counter preparations of ibuprofen or naproxen sodium are readily available. However, one should advise patients to try these only after they have tried to achieve pain relief with simple analgesics. These agents are not recommended for individuals with a history of peptic ulcer disease (PUD), gastritis or other gastrointestinal problems.

When treating older patients with comorbid conditions, clinicians should exercise caution when patients note NSAIDs on their list of current medications or when considering the use of prescription NSAIDs due to the aforementioned risk of possible drug interactions and a possible effect on kidney function. Aspirin is not usually recommended in the treatment of OA because of the doses required for pain relief and possible adverse effects on the gastrointestinal tract and stomach.

Nutritional Supplements: A Worthwhile Addition To The OA Armamentarium?
Despite some controversy, nutritional supplements have emerged for the treatment for OA. The most common of these supplements are glucosamine and chondroitin sulfate, substances that are naturally found in the body. Glucosamine stimulates the formation and repair of articular cartilage while chondroitin is produced to combat body enzymes from degrading joint cartilage. Both glucosamine and chondroitin sulfate supplements are available to the public. Other preparations can include avocado-soybean unsaponifiables, ginger and willow.

While glucosamine and chondroitin sulfate supplements have few reported side effects, it is important to note that neither glucosamine, chondroitin or any of these other substances have been analyzed or approved by the Food and Drug Administration (FDA) prior to becoming available to the general public. Regardless, many providers are open to the use of these supplemental therapies.

Some supplements, particularly glucosamine, affect glucose metabolism and insulin resistance so it is important to advise patients with diabetes to avoid these compounds. Also, when patients are considering the use of these supplements, let them know that they may not notice an effect for up to four weeks. Be sure to let patients know they should discontinue the use of the supplement at any sign of adverse effects and report to a provider before continuing the regimen.

When Patients Ask About Topical Preparations
Topical preparations provide other OTC options for patients with OA. Patients can apply these to help reduce inflammation below the skin and to alleviate nerve pain associated with OA. Topical preparations include anesthetics, analgesics and rubefacients.

Anesthetics help reduce or eliminate pain in limited areas by interrupting nerve impulses. One example is a combination of prilocaine and lidocaine (EMLA) that can numb the skin for two to three hours. Analgesics are generally some form of NSAID in cream, gel or ointment form that can reduce swelling and ease inflammation. Examples of such analgesics are capsaicin (Zostrix, Health Care Products), ketoprofen (Orudis Gel, Aventis Pharma) and diclofenac sodium (Voltaren Emugel).

Rubefacients produce a reddening effect on the skin and stimulate blood flow, giving a sensation of warmth. BenGay and IcyHot are examples of rubefacients that have no added analgesics. Other compounds, such as Aspercream and Sportscream, contain salicylates as an added analgesic.

However, if patients ask you about the use of topical preparations, you should discuss the same precautions and possible side effects you would discuss with tablet NSAIDs since topical medications are absorbed through the skin and into the bloodstream. One should also advise patients to wash their hands after application and to avoid getting the substance in their eyes or in any open wounds.

A Closer Look At NSAIDs
While simple analgesia such as acetaminophen may be the first choice in treating OA, NSAIDs are the most commonly used therapy. This stems from the fact that irritation due to a breakdown of the articular cartilage results in increased inflammation at the joints. Also bear in mind that NSAIDs have analgesic properties as well as antiinflammatory effects. That may be why approximately two to four million people in America, many of whom are over the age of 65, take these types of medications on a daily basis.

There is no significant difference in effectiveness between the various classes of NSAIDs. However, when you are weighing the use of a particular therapy, consider the patient’s age, kidney function and liver function, and your own clinical experience with the medication in order to select the appropriate medication.
Also be aware that there are a number of major side effects and toxicities that can occur with overuse of traditional NSAIDs. These side effects can include but are not limited to: stomach ulceration, gastric bleeding, kidney damage and loss of platelet function resulting in increased bruising.

A Guide To Commonly Used NSAIDs For OA

In 1998, Cox-2 inhibitors became available. They became the preferred NSAIDs because they were as efficacious as the traditional NSAIDs but had a reduced risk for significant side effects such as blood thinning and stomach ulceration.
Celecoxib (Celebrex, Pfizer) was the first Cox-2 inhibitor. Rofecoxib (Vioxx) and valdecoxib (Bextra) emerged in 1999 and 2001. However, rofecoxib and valdecoxib were removed from the market in the United States in 2004 and 2005 respectively due to cardiovascular side effects. Valdecoxib also was cited for an increased risk of serious and possibly life-threatening skin reactions. Celecoxib is currently the only Cox-2 inhibitor that still remains on the market. A boxed warning has been added to the celecoxib medication profile that notes the potential of an increased risk of cardiovascular complications.

Pertinent Pointers On Prescribing Analgesic Medications
Analgesic medications, unlike NSAIDs, do not help in reducing inflammation. The primary function of these medications is reducing the joint pain associated with OA. As we mentioned earlier, acetaminophen is the most commonly used analgesic because of its tolerability and availability without a prescription.

However, you may need to prescribe certain analgesic medications to patients with more advanced disease or pain levels. These medicines include acetaminophen with codeine (Tylenol with codeine, Johnson and Johnson), oxycodone (OxyContin, Purdue Pharma), hydrocodone/acetaminophen (Vicodin, Abbott), propoxyphene hydrochloride (Darvon, Xanodyne) and tramadol (Ultram, Ortho-McNeil). These preparations (except tramadol) are narcotic pain relievers. It is important to monitor the use of these medications as patients may develop a dependency to these drugs over time.

What You Should Know About Injections For OA
Clinicians may consider the use of corticosteroid injections as a supplement to oral therapy or as the primary treatment for OA. This type of steroid is a natural product of the adrenal glands. Corticosteroids suppress the immune system and act against inflammation. When it comes to treating OA, one would administer corticosteroid injections directly into the affected joints. Advise patients to avoid overuse of the injected joint to help ensure the maximum beneficial effect. Clinicians should limit corticosteroid injections of joints to two to three times a year. Too frequent injections and the overuse of corticosteroids can lead to damage to joint structures.

Another form of injection therapy involves viscosupplementation.
Viscosupplementation involves injecting a form of hyaluronate into the knee. Hyaluronic acid is a natural component of synovial fluid. It helps in reducing inflammation as well as improving joint lubrication. In osteoarthritis, hyaluronic acid is affected and does not function as well as it should.

When treating osteoarthritis of the knee, clinicians may use viscosupplementation drugs to supplement the naturally produced hyaluronic acid in the synovium.

Accordingly, one may use viscosupplementation drugs such as hylan G-F 20 (Synvisc, Genzyme), sodium hyaluronate (Hyalgan, Sanofi-Aventis) or hyaluronan (Supartz, Smith and Nephew) to supplement the naturally produced hyaluronic acid in the synovium. Other viscosupplementation agents include one percent sodium hyaluronate (Euflexxa, Ferring Pharmaceuticals) and high molecular weight hyaluronan (Orthovisc, Ortho-McNeil). Injection dosing varies for the different viscosupplementation agents. Unfortunately, in our experience, these medications are not readily covered by prescription plans and may be expensive to the general patient population.

Case Study: When A Patient Presents With Lower Back And Joint Pain
Brad is a 65-year-old, African-American male with a chief complaint of severe low back pain and associated joint pain in the hands and wrists bilaterally. He presents with no history of trauma and the pain has grown progressively worse over the past two weeks. His wife gave him some ibuprofen she uses for her own back pain. He denies relief of symptoms but does report an occurrence of abdominal pain on the three occasions that he took the ibuprofen. He denies associated nausea, vomiting or diarrhea. The patient says he is having more joint pains than before but denies muscle pain or spasm, weakness or previous injuries or fractures.

The past medical history reveals a diagnosis of hypertension and Type II diabetes. Medications include metoprolol and metformin for these conditions. With the exception of the ibuprofen given to him by his wife, he denies use of other prescription, non-prescription or supplement medications. He is a cigarette smoker and social drinker. He has no known allergies. Brad is a recently retired construction worker and his job involved heavy lifting and increased physical activity. The remaining history was noncontributory.

During the patient’s physical examination, we noted a decreased range of motion of the lumbar spine due to pain and stiffness. All other joints were aligned and symmetrical. However, we did observe some tenderness in both knees and wrists with manipulation. The abdominal exam was benign and guiac was negative for occult blood. The remainder of the physical exam was within normal limits. Radiographs of the L/S spine and wrists revealed mild to moderate OA.

We prescribed a regimen of celecoxib 100 mg BID. We also gave the patient information about the medication and advised him to discontinue treatment in the event his abdominal pain recurred. We told the patient he could supplement this medication with OTC acetaminophen as needed. We also discussed the use of supplements such as glucosomine and chondroitin, and encouraged the patient to begin a progressive exercise protocol as tolerated with proper warm-up and warm-down phases. A follow-up visit was scheduled in four weeks.

The patient was compliant with his medication regimen and progressive exercise program. He demonstrated some improvement with no other side effects at the four-week follow-up. He has continued improving over subsequent visits.

In Conclusion
There are a multitude of different medications for the treatment of OA. They range between non-prescription and prescription medicines that include narcotics (Class II/III) as well as oral, topical and injectable preparations. As with any treatment plan, the decision of which medications to use needs to be appropriate to the individual patient. Treatment options should be dependent upon the severity of the condition, age, additional medical history, potential side effects and previously used therapies in addition to non-medicinal forms of treatment that the patient may also be utilizing.

It is also important for patients to be compliant with the treatment plan and take medications as directed. Clinicians should discuss potential side effects and encourage patients to report them if and when they occur. While nutritional supplements may have some value, clinicians should also discuss these with patients in order to reduce the risk of any possible side effects or drug interactions.