Nonprescription Management of Osteoarthritis

January 1, 2002

L. Kendall Shaw, PharmD

Article

What Is Osteoarthritis?

Osteoarthritis is the most common joint problem in people older than 70 year of age, affecting an estimated 60 million people in the United States alone, and is far more common than rheumatoid arthritis. A major cause of limited activity, it surpasses the combined mobility impact of both stroke and dementia. Although some people with the condition experience only mild pain despite extensive joint damage, osteoarthritis pain can be debilitating, even with only mild damage to the affected joints. Pain, swelling, warming, reddening, stiffness, and audible creaking of osteoarthritic joints are common symptoms. Any joint can be affected, and it is most common in joints that endure frequent and heavy use. Weight-bearing joints are particularly vulnerable to long-term damage, especially in someone even slightly overweight. Joints injured sometimes much earlier in life are frequently the sites of significant damage and severe pain, and it is common for symptoms to vary with weather and climate as well as level of joint use.

Unlike rheumatoid arthritis, an autoimmune disease in which the immune system actively damages affected joint tissues, osteoarthritis is more a function of ?wear and tear? that affects people as they age. Joints are very complex and must move smoothly and cushion impacts for many years. Normally, cartilage and other tissues and fluids protect the joint and form a perpetually replenished slippery surface that prevents the ends of adjoining bones from grinding together. Like most tissues in the body, these protective layers are constantly torn down and rebuilt, reforming and renewing the intricate latticework that makes up the joint surfaces. With age, the ability to rejuvenate these tissues and maintain proper balance in lubricating fluids gradually diminishes, exposing the cartilage to damage that is repaired more slowly. With continued use and injury, the cartilaginous surfaces begin to deteriorate faster than they can be repaired, developing fissures, losing their normal elasticity, and in severe cases, completely breaking down and allowing the bone ends to grate against each other. The perpetual inflammatory response to such tissue damage undoubtedly contributes to the disease process and symptom severity, especially swelling, reddening, and pain.

Risk Factors

Advancing age?Evidence of osteoarthritic damage is detectable by radiography in 80% of those older than 75 years of age, even those not experiencing joint pain.
Gender?Up to approximately 65 years of age, equal numbers of men and women develop osteoarthritis, but it becomes more common in women after that age.
Obesity?Being overweight, even slightly, increases the workload and strain on weight-bearing joints.
Physical activity?Movements that stress joints increase the risk of developing osteoarthritis as well as the likelihood of outright injury to the joints that may greatly accelerate the osteoarthritic processes.
High-impact exercises?Exercises such as jogging or playing tennis put strain on the knees, hips, and ankles.
Repetitive heavy lifting/improper lifting?Lifting stresses the joints of the spine.
Repetitive motion?Even relatively low-impact motions, such as frequent computer use, can affect joints of the fingers, hands, wrists, and arms.
Lack of exercise?Underuse of the muscles and the other tissues that normally support and protect the joints can leave them weak and the joint unduly vulnerable to injury and damage.
Other diseases?Diseases such as diabetes, gout, hormonal imbalances, and even high blood pressure are also associated with significant increases in incidence of osteoarthritis.

Treatment

Treatments aim to relieve pain and preserve mobility. Most experts recommend treating osteoarthritis in stages to avoid causing more health problems.

Step 1: Lifestyle changes?Joint pain and stiffness discourage mobility, often leading to weight gain, both of which further contribute to the disease process; so exercise and weight reduction are logical first-line remedies. It is important to understand that the wrong kinds of exercise can do more damage than good, so consultation with a physician or physical therapist is a must. Exercises should carefully avoid impact on the diseased joints and help in weight reduction?a loss of only 10 lb can cut the risk of developing osteoarthritis in half. Additional nonpharmacologic interventions may contribute significantly to reducing symptoms and slowing progression of the disease and include the following:

A healthy attitude
Pain coping skills
Physical therapy (aerobic, range of motion, muscle strengthening)
Use of heat, ice, massage
Occupational therapy
Proper footwear and lateral-wedge insoles for knee and ankle joints
Joint protection with bracing and/or assistive devices for walking and daily activities

Step 2: Medication may be a necessary second step. Acetaminophen is often considered a reasonable first choice for many patients. It does little for inflammation, but it will sometimes provide adequate pain control. Up to 4,000 mg daily of acetaminophen is usually safe for most people with normal liver and kidney function, but anyone taking that much acetaminophen should avoid or at least strictly limit alcohol intake and consult a physician or pharmacist about potential interactions with other medications.

Joint damage is often accompanied by inflammation that contributes to the pain and swelling of osteoarthritis. Therefore, while acetaminophen may be a viable choice for pain, the nonsteroidal anti-inflammatory drugs (NSAIDs) generally produce better results, because they treat both the pain and the inflammation. A recent study published in The Journal of Rheumatology found that NSAIDs were ranked by patients as ?most helpful over acetaminophen or an analgesic drug.? Nonprescription doses are frequently sufficient; and naproxen sodium (Aleve) offers the convenient advantage of efficacy with only one tablet twice daily, as opposed to ibuprofen and acetaminophen, which require two tablets up to four times daily for comparable efficacy. The 12-hour efficacy of naproxen sodium can be a significant economic advantage as well. This class of medications can occasionally cause some significant side effects, but they are usually associated with high doses and extended use. Older people are significantly more susceptible to side effects, such as stomach irritation or ulceration and compromise of kidney function. Combinations of chondroitin and glucosamine, although not FDA-approved to treat osteoarthritis, have provided relief for some patients as an alternative therapy. These nonprescription supplements are readily available, with minimal potential for side effects.

The application of heat or cold to affected joints can often help relieve pain, and camphorated or mentholated rubs are successful options for some people. Capsaicin, a natural component of hot peppers, formulated into a topical cream and applied to the skin over affected joints has been shown to be quite effective with repeated application. It usually requires application about four times daily, which may cause stinging and reddening of the skin for up to 2 weeks before significant pain relief is noticed. These topical preparations should never be used with a heating pad, as they can cause burns.

Conclusion

Although invasive medical procedures, painful injections into affected joints, or major medical therapy may be necessary in patients with severe osteoarthritis, many milder cases can be successfully managed by more simple means. The choice of nonprescription options should be guided by a health care professional who can help assess the extent of the disease and severity of symptoms to treat them effectively with the best chance of avoiding side effects. The physician and pharmacist can be invaluable allies in finding the right nonpre-scription option for patients.