Many Choices for Pharmacists Counseling Osteoarthritis Patients

Greta M. Pelegrin, PharmD, and Damaris Torres, PharmD Candidate
Published Online: Saturday, September 1, 2007

Osteoarthritis (OA), also known as degenerative joint disease, is characterized by gradual loss of cartilage. It is the most common form of arthritis in the United States and a major factor in chronic disability. Those patients with OA generally have pain when undergoing physical activity and weight-bearing exercise; this pain improves with rest. Unlike other conditions such as rheumatoid arthritis, inflammation in OA is usually mild and limited to the affected joint(s). Inflammation is typically seen in older patients; however, young people can develop it, usually as a consequence of a joint injury, joint malformation, obesity, or genetic factors. Symptoms usually occur earlier in life in women, yet prevalence is equal among men and women.

Osteoarthritis affects primarily the weight-bearing joints of the axial and peripheral skeleton, causing pain, limitation of motion, deformity, and progressive disability. Patients with OA usually feel joint pain and stiffness. The most commonly affected joints are those in the hands, neck, lower back, knees, and hips. There is no cure for OA, but treatment is aimed at alleviating pain and improving quality of life.

The aging process leads to OA, yet other factors increase the risk as well:

  • Injuries resulting from certain sports or other physical activity, causing joints to degenerate
  • Gender?women are more likely to develop OA
  • Genetics
  • Obesity?excess weight affects joints

Treatment

As OA progresses, prolonged stiffness and enlargement of the joints may be evident, including limitation of daily activities.

Treatment is aimed at reducing pain, improving function of the affected joints, decreasing stiffness, and preventing or decreasing disability, as well as improving quality of life. Yet, treatment is patient-specific and consists first and foremost of educating the patient and family members about the course of the disease, as well as preventive measures and treatment modalities.

Exercise has been shown to be extremely helpful in building muscle strength, enhancing flexibility, and resulting in weight reduction. Physical therapy, support devices, and heat are other options. Other devices include appropriate footwear, walking canes, knee braces, and heel wedging.

Drug Therapy

Osteoarthritis is best managed with a combination of nonpharmacologic therapy and drug therapy. Drug therapy includes both prescription and OTC medications?acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) when there is inflammation involved, cyclooxygenase-2 (COX-2) specific inhibitors, and topical formulations such as capsaicin. For more severe pain, stronger prescription drugs are available, as well as injectable corticosteroids and hyaluronic acid.

Acetaminophen

The American College of Rheumatology recommends acetaminophen as first-line therapy for OA for its effectiveness in treating patients with mild-to-moderate pain, but it does not treat inflammation. It is cost-effective, is available OTC in various strengths, and generally causes fewer adverse effects than NSAIDs. The daily dose should not exceed 4 g, and regular alcohol consumption when combined with acetaminophen can result in liver toxicity.

NSAIDs

For those patients who do not improve with acetaminophen and who experience inflammation, NSAIDs are the gold standard in treating OA. NSAIDs include OTC products such as aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve), with ibuprofen and naproxen available by prescription in higher strengths. Those available by prescription only include nabumetone (Relafen), diclofenac (Voltaren, Cataflam), piroxicam (Feldene), and meloxicam (Mobic). All NSAIDs are presumed to have the same therapeutic effects, depending on the patient, yet they are to be used cautiously in the elderly because of gastrointestinal (GI) and renal adverse effects. Because inflammation plays a small role in OA, studies have shown that there is no advantage to using NSAIDs over acetaminophen.

Topical Pain Relievers

Many OTC products are available in the form of creams, ointments, and gels. They contain ingredients such as menthol, camphor, and salicylates. Capsaicin, a topical formulation made from hot chili peppers, is often recommended in conjunction with oral agents. It reduces pain by depleting substance P, a chemical involved in the transmission of pain. It should be used qid, and the best results are seen after a few weeks of daily use.

Other Agents

Celecoxib (Celebrex), the only COX-2 inhibitor presently on the market, has equal therapeutic effect to NSAIDs, but it can still produce adverse GI effects. Hyaluronic acid is a component of both cartilage and synovial fluid and helps maintain joint function. It is available in intra-articular injections under the brand names of Hyalgan and Synvisc.

Tramadol (Ultram), a centrally acting drug, has no therapeutic effect on inflammation but can be used for pain relief with less of the GI side effects caused by NSAIDs. Injectable corticosteroids are occasionally used but only on a short-term basis due to their adverse side effects.

Glucosamine, often combined with chondroitin, is available OTC. It has been studied extensively, and many studies have shown analgesic efficacy in treating OA. These agents are for the most part safe but may take several weeks to stimulate the production of building blocks of cartilage.

Important Points in Dealing with Osteoarthritis


Suggested Reading

Altman R, Hochberg M. Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis Rheum. 2000;43(9):1905-1915.

Altman RD. Osteoarthritis: Aggravating factors and therapeutic measures. Postgrad Med. 1986; 80(2):150-163.

American College of Rheumatology. Osteoarthritis. Available at: www.rheumatology.org/public/factsheets/oa_new.asp. Accessed June 14, 2007.

Boh L, Elliot E. Osteoarthritis. In: Dipiro JT, Talbert RC, Yee GC, et al. Pharmacotherapy: A Pathophysiologic Approach. 5th ed. New York, NY: McGraw-Hill; 2001:1639-1656.

Haq I, Murphy E, Dacre J. Osteoarthritis. Postgrad Med J. 2003;79:377-383.

Hinton R, Moody RL, Davis AW, Thomas SF. Osteoarthritis: diagnosis and therapeutic considerations. Am Fam Physician. 2002;65(5):841-848.

Mayo Clinic. Osteoarthritis. www.mayoclinic.com/health/osteoarthritis/DS00019. Accessed June 11, 2007.

Singh G. Treatment options for osteoarthritis. Surg Technol Int. 2003;11:287-292.



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