Joint Pain
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.
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OA and rheumatoid arthritis are 2 of the most prevalent causes of joint pain. Other medical conditions that can cause joint pain include gouty arthritis, lupus, bursitis, tendonitis, and osteomyelitis.3,4 In addition, examples of other possible contributors to 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.3,4 Only the pain associated with OA is approved for self-treatment after an initial medical diagnosis has been established.5 Statistics from the Arthritis Foundation report that an estimated 27 million individuals in the United States have some degree of OA.6,7 Whereas OA can occur in any joint, the condition most often affects the weight-bearing 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.3,6
In general, the goals for treating OA include improving an individual's quality of life by providing pain relief and enhancing joint mobility. Selection of treatment is dependent upon various factors, including severity of the OA, the patient's medical history, current medication profile, and allergy history. After these factors are evaluated for potential contraindications, the elected therapy may include one or more of the following: systemic and topical pharmacologic agents, physical therapy, rest, heat and cold therapy, weight loss, the use of devices to take strain off of joints, such as canes and splints, and surgery, when warranted. OTC analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of OA. Acetaminophen, when compared with NSAIDs, is considered to be the drug of choice for the treatment of OA when inflammation is not a chief concern because of its reduced adverse effect profile.5 NSAIDs are the preferred drugs of choice, however, when inflammation also is present and no potential contraindications or drug interactions are present.5
Topical Therapies
Topical products used for treating joint pain can be used in conjunction with systemic agents or as the sole therapy of choice. They 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 apply topical products only to skin that is intact and should not cover areas treated with counterirritants with tight bandages or occlusive dressing.5 Patients also should be advised not to use heating devices with topical counterirritants.5 Topical patches for treating joint pain are available in various sizes that provide 8 to 12 hours of continual heat therapy.
Dietary Supplements
Also available for the treatment of joint pain are various dietary supplements, such as glucosamine, chondroitin sulfate, methylsulfonylmethane (MSM), and S-adenosyl-L-methionine (SAMe). These supplements are available as either single-entity or combination products. Studies have shown that glucosamine sulfate not only reduces the pain associated with OA but may also slow down the progression of the disease.8
Glucosamine is an endogenous mucopolysaccharide used in the synthesis of cartilage.9,10 The most common adverse effects of glucosamine include mild gastrointestinal upset, nausea, heartburn, and diarrhea, which can be alleviated if it is taken in divided doses with meals.10 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 should be advised to discuss the use of this product with their physician prior to use.10 Chondroitin sulfate is a glycosaminoglycan made from glucuronic acid and galactosamine present in animal cartilage and helps cartilage retain water.10,11
MSM also has been added to many of the glucosamine/ chondroitin supplement products. MSM is a sulfur source that is released on breakdown by intestinal bacteria.10 Although its exact mechanism of action with regard to OA is unclear, MSM has an essential role in maintaining the elasticity and flexibility of the connective tissue that makes up joints.11,12 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 or months.10
SAM-e is produced primarily in the liver.10 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.10 SAM-e should not be used in conjunction with antidepressants and 5-HT1 agonists because of an increased risk of serotonin syndrome.10
More information on these supplements can be found at the National Institutes of Health's National Center for Complementary and Alternative Medicine Web site at nccam.nih.gov.
The Role of the Pharmacist
Prior to recommending any of these OTC products, pharmacists should always assess the appropriateness of selftreatment by evaluating the patient's symptoms, review the patient's medical history, drug profile, and allergy history, and screen for drug?drug interactions and possible contraindications associated with the use of these products. Furthermore, pharmacists should remind patients currently taking any other medications, those with preexisting conditions, and women who are pregnant or lactating to always consult a physician before using any of these products. Key points to address during counseling include the proper use (dosage and administration guidelines) of these products, as well as potential adverse effects. Pharmacists also can make recommendations about nonpharmacologic measures that patients may incorporate into their treatment regimen to help alleviate joint pain. Patients with severe and continual (or worsening) joint pain should be encouraged to seek further evaluation and treatment from their primary health care provider, when warranted.5 For more information regarding OA and its treatment and management, please visit the following Web sites:
- Arthritis Foundation Web site: www.arthritis.org.
- National Institute of Arthritis and Musculoskeletal and Skin Diseases Web site: www.niams.nih.gov.
- CDC Web site: www.cdc.gov.
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References
- Baer A, Patel V, McCormack R. The approach to the painful joint. Emedicine Web site. www.emedicine.com/med/topic3562.htm. Accessed December 11, 2008.
- QuickStats: percentage of adults reporting joint pain or stiffness—national health interview survey, United States, 2006. MMWR Morb Mortal Wkly Rep. Centers for Disease Control and Prevention Web site. www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a9.htm. Accessed December 11, 2008.
- Arthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Web site. www.niams.nih.gov/Health_Info/Osteoarthritis/osteoarthritis_ff.asp. Accessed December 11, 2008.
- Joint Pain. National Institutes of Health's Medlineplus Web site. www.nlm.nih.gov/medlineplus/ency/article/003261.htm. Accessed December 11, 2008.
- 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.
- Osteoarthritis. Arthritis Foundation Web site. www.arthritis.org/disease-center.php?disease_id=32. Accessed December 11, 2008.
