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A Pharmacist's Guide to OTC Therapy: Osteoarthritis

Yvette C. Terrie, BSPharm, RPh
Published Online: Monday, September 1, 2008   [ Request Print ]


Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.



Arthralgia, commonly referred to as joint pain, can be attributed to various causes, including many types of injuries and medical conditions. Two of the most common causes of arthralgia are osteoarthritis and rheumatoid arthritis.1 Although medical conditions such as rheumatoid arthritis, osteoarthritis, gouty arthritis, lupus, bursitis, tendonitis, and osteomyelitis may cause arthritic pain, according to the Handbook of Nonprescription Drugs, only the pain associated with osteoarthritis is approved for self-treatment after an initial medical diagnosis is established.1,2

Other possible causes of joint pain include excess weight, increasing age, genetic defects in joint cartilage, sedentary lifestyle, and stress on the joint from certain sports activities or occupations.1

Statistics from the Arthritis Foundation report that an estimated 27 million individuals in the United States have some degree of osteoarthritis.3 Whereas osteoarthritis can occur in any joint, the condition most often affects the weightbearing joints of the hips, knees, and lower back. It also can affect the neck, small finger joints, the base of the thumb, and the big toe.3

The goals of treating osteoarthritis include relief of pain, enhancing mobility of the joints, and improving the patient's quality of life by minimizing the pain associated with this condition. The treatment selected depends on the severity of the osteoarthritis and may include the use of pharmacologic agents, physical therapy, rest, heat and cold therapy, weight loss, and the use of devices to take strain off joints, such as canes and splints, and surgery, if needed. OTC analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of osteoarthritis. Due to its reduced adverse effect profile when compared with NSAIDs, acetaminophen is the drug of choice for treating osteoarthritis when inflammation is not a chief concern.2 NSAIDs are preferred when inflammation is present. Patients should be screened for potential contraindications and drug interactions, however, prior to using any of these OTC analgesics.

In addition to the use of systemic agents, a variety of topical products are available for treating joint pain. They can be used in conjunction with systemic agents or as the sole therapy of choice. These products may contain one or more of the following ingredients: methyl salicylate, camphor, menthol, methyl nicotinate, capsaicin, or trolamine salicylate, and are available as gels, ointments, creams, lotions, and patches. Patients should be advised to only apply topical products to skin that is intact and to not cover areas treated with counterirritants with tight bandages or occlusive dressing. 2 Patients also should be advised not to use heating devices with topical counterirritants.2 Also available for treating joint pain are topical heat therapy patches available in various sizes that provide 8 to 12 hours of continual heat therapy.

In addition to systemic and topical analgesics, various dietary supplements, such as glucosamine, chondroitin sulfate, methylsulfonylmethane (MSM), and S-adenosylmethionine (SAM-e) have been used for the treatment of joint pain. These supplements are available as either single-entity or combination products. Studies have shown that glucosamine sulfate not only reduces the pain associated with osteoarthritis, but also may slow down the progression of the disease.3

Glucosamine is an endogenous mucopolysaccharide used in the synthesis of cartilage.4,5 The most common adverse effects of glucosamine include mild gastrointestinal (GI) upset, nausea, heartburn, and diarrhea, which can be alleviated if taken in divided doses with meals. Glucosamine should not be used if an individual is allergic to shellfish. Patients with diabetes should be aware of the possibility of hyperglycemia when using glucosamine and discuss the use of this product with their physician prior to use.5 The most common adverse effects of chondroitin include mild GI upset and nausea.5

MSM has been added to many of the glucosamine/chondroitin supplement products. Although its exact mechanism of action with regard to osteoarthritis is unclear, MSM has a crucial role in maintaining the elasticity and flexibility of the connective tissue that make up joints.6,7 Patients should be advised that these supplements will not provide pain relief as quickly as NSAIDs or acetaminophen, and their therapeutic effects may not be evident for several weeks.5

Another supplement that promotes joint health is SAM-e, which is produced primarily in the liver.5 It is best known and marketed as a mood stabilizer. Both liver disease and low levels of vitamin B12 and folate may reduce SAM-e levels.5 SAM-e should not be used in conjunction with antidepressants and 5-HT1 agonists because of an increased risk of serotonin syndrome.5

The Role of the Pharmacist

Prior to recommending any of these OTC products, pharmacists should assess the appropriateness of self-therapy by evaluating the patient's symptoms and review the patient's current medical history, drug profile, and allergy history, and screen for drug?drug interactions and possible contraindications. Patients who are currently taking any other medications, those with preexisting conditions, and women who are pregnant or lactating should always consult a physician before using any of these products. Patients should always be counseled on the proper use and adverse effects of these OTC agents and should be reminded to use these products as directed.

In addition, patients with severe and continual joint pain should be encouraged to seek further evaluation and treatment from their primary health care provider, when warranted, and if they see no signs of improvement or if pain worsens. To provide more information to your patients, please visit the following Web sites:

  1. Suggestions from the Arthritis Foundation on Protecting Your Joints. Arthritis Foundation Web site: www.arthritis.org/protect-your-joints.php.
  2. Do I Have Arthritis? National Institutes of Health's National Institute of Arthritis and Musculoskeletal and Skin Diseases Web site: www.niams.nih.gov/Health_Info/Arthritis/tengo_arthritis.asp.

References

  1. Arthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases Web site. www.niams.nih.gov/Health_Info/Osteoarthritis/osteoarthritis_ff.asp. Accessed July 5, 2008.
  2. Wright E. Musculoskeletal Injuries and Disorders. In: Berardi RR, Kroon LA, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 15th ed. Washington, DC: American Pharmacists Association; 2006:111-129.
  3. Osteoarthritis. Arthritis Foundation Web site. www.arthritis.org/disease-center.php?disease_id=32. Accessed July 5, 2008.
  4. Questions and Answers: NIH Glucosamine/Chondroitin Arthritis Intervention Trial. NIH's National Center for Complementary and Alternative Medicine Web site. nccam.nih.gov/research/results/gait/qa.htm#b2. Accessed July 5, 2008.
  5. McQueen C. Nonbotanical Natural Medicines. In: Berardi RR, Kroon LA, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 15th ed. Washington, DC: American Pharmacists Association; 2006:1148-1150.
  6. Advanced MSM. Osteo Bi-flex Product Information Web site. www.osteobiflex.com/pages/products.aspx?PPID=4. Accessed July 5, 2008.
  7. Naturemade TripleFlex Product Information. Naturemade Web site. www.naturemade.com/ProductDatabase/prd_prod.asp?productid=73. Accessed July 5, 2008.
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