Eight Treatments Commonly Used for Osteoarthritis Pain

Osteoarthritis, a common condition involving the loss of cartilage and, sometimes, bone in the joints, leads to joint pain and difficulty moving. It usually affects the knees, hips or hands.[1] Joints affected by osteoarthritis are sometimes capable of self-repair, and in many cases, pain will decrease over time.[2] Yet pain from this condition can persist for years, interfering with quality of life.

Several treatment approaches are commonly used to reduce this pain, but they vary greatly in safety and effectiveness. Eight of these treatments follow. Public Citizen’s Health Research Group lists some of them as Do Not Use.

1. Exercise and weight loss
Exercise strengthens the muscles supporting the joint and, at least for osteoarthritis of the knee, is effective at treating pain regardless of its severity.[3] For overweight and obese adults with knee osteoarthritis, pairing exercise with a weight loss diet increases the likelihood they will experience meaningful pain relief.[4]

Advice for patients: Work with your doctor to develop an appropriate exercise program. Combine this with a weight loss program if you are overweight or obese.

2. Acetaminophen
Acetaminophen (TYLENOL) is a pain-relieving drug that has shown a small benefit over a placebo in randomized, controlled trials for osteoarthritis.[5] While not as effective as other pain relievers, when taken at the recommended dose, it has very few serious side effects, making it a good first choice for treatment.[6] However, taking more than the maximum recommended daily dose, or combining the recommended dose with more than three alcoholic drinks per day, may result in irreversible liver damage.[7]

Advice for patients: Try acetaminophen first for pain relief.

3. Oral nonsteroidal anti-inflammatory drugs
Nonsteroidal anti-inflammatory drugs, or NSAIDs, can relieve pain and also reduce inflammation, which is common in osteoarthritis. Commonly used NSAIDs include diclofenac (ARTHROTEC, CAMBIA, CATAFLAM, VOLTAREN XR, ZIPSOR, ZORVOLEX), ibuprofen (ADVIL, IBUPROHM, IBU-TAB, MIDOL LIQUID GELS, MOTRIN IB, PROFEN, TAB-PROFEN), naproxen (ALEVE, ANAPROX, NAPRELAN, NAPROSYN) and aspirin.

NSAIDs are more effective than acetaminophen in treating pain, but they also carry serious side effects, particularly for elderly patients. Among the adverse effects of many NSAIDs are gastrointestinal problems — ulcers, abdominal pain and bleeding — and increased risk of cardiovascular problems, including heart attack, increased blood pressure and stroke.[8],[9]

All NSAIDs are not alike in terms of safety risks. Diclofenac significantly increases the risk of heart problems and stroke, a risk that led Public Citizen’s Health Research Group to recommend against the use of this drug in pill form.[10]

By contrast, naproxen does not cause increased risk of heart problems.[11] Ibuprofen does carry some risk of increased heart attack, but it is less dangerous to the digestive system than naproxen, making it the best choice for patients with prior gastrointestinal issues and low risk of heart trouble and stroke.[12]

Advice for patients: If acetaminophen provides inadequate pain relief, try ibuprofen or naproxen. Start at the lowest possible dose, and use for as short a time as possible to minimize risk of side effects.

4. Topical NSAIDs
NSAID creams, gels and other treatments applied to the skin, known as topical treatments, can be effective for treating pain in the knee or hands, but not hip joints.[13]

Diclofenac is currently the only NSAID approved by the Food and Drug Administration (FDA) for topical use. It is sold as a gel (SOLARAZE, VOLTAREN GEL) or solution (PENNSAID).

Doctors in the U.S. may recommend topical diclofenac only to patients who cannot take an NSAID pill due to side effects. However, in England, the National Institute for Health and Care Excellence has recommended trying topical NSAID treatments before NSAID pills, because this lowers overall exposure to NSAIDs and reduces the risk of side effects.[14]

Randomized, controlled trials have shown topical diclofenac to be as effective as oral NSAIDs in controlling pain.[15] Levels of the drug in the blood are about 10 times lower than similar dosing with NSAID pills, because medication that is rubbed on the skin tends to stay in the tissue near the joint rather than moving throughout the body.[16] There is some evidence that topical treatments are less likely to cause adverse side effects compared with oral NSAIDs.[17]

Advice for patients: Topical diclofenac is a safe and effective alternative to NSAID pills for treating hand or knee osteoarthritis. Consider switching to this treatment if oral NSAIDs cause significant side effects.

5. Capsaicin cream
Capsaicin, the ingredient in chili peppers that causes the spice’s burning sensation, is sold in over-the-counter topical preparations under many names (CAPSAICIN ARTHRITIS PAIN RELIEF CREAM, CAPSAICIN-HP, CVS CAPSAICIN, MEIJER CAPSAICIN, among others) and is available by prescription as the topical patch QUTENZA. Capsaicin works by overstimulating the nerves that cause pain, reducing their ability to signal joint pain.[18] This mechanism is sometimes referred to as a counterirritant.

A small number of randomized, controlled trials have shown that capsaicin cream can reduce pain when rubbed on the hands or knees — at least in the short term, for up to 12 weeks.[19]

The side effects are mainly minor: rash, burning sensation and other irritation to the skin. However, the FDA has received a few reports of more serious burns with capsaicin products.[20] These burns are more commonly reported for products containing menthol, another potential irritant that is sometimes mixed together with capsaicin and sold as a combined cream.[21]

Advice for patients: Capsaicin can be used with or without other pain relievers. When using it for the first time, apply to only a small area and wait to ensure no signs of irritation before applying more broadly.

6. Celecoxib
Celecoxib (CELEBREX) is a member of a class of drugs known as COX-2 inhibitors. Another COX-2 inhibitor, rofecoxib (VIOXX), was pulled from the market following a study showing it dramatically increases risk of heart attacks.[22] The COX-2 inhibitor valdecoxib (BEXTRA) also was pulled from the market because it causes rare but serious skin reactions.[23]

There is evidence that celecoxib carries similar heart and skin risks, and the drug offers no advantage in terms of effectiveness or safety compared with older NSAID treatments.[24],[25]

Advice for patients: We have classified classified celecoxib as Do Not Use for osteoarthritis pain or other purposes.

7. Steroid injections
Steroids can reduce inflammation, and randomized, controlled trials have shown that steroid injections are more effective than placebo injections for osteoarthritis of the knee, but not the hip or hands.[26]

The effectiveness is very short-lived, however, with pain beginning to return after about a week.[27] Repeating injections over a longer period — one or two years — does not decrease pain, and excessive use of steroids can weaken bones, increasing the risk of fractures.[28]

Steroid injections also are not effective for all patients, possibly because not all osteoarthritis pain involves inflammation.

Advice for patients: Steroids may be used to treat flare-ups of knee pain while participating in an exercise program to strengthen joint muscles. Do not use repeated steroid injections for continuous pain.

8. Glucosamine and chondroitin
Glucosamine and chondroitin are dietary supplements believed to affect joint health. The combination is marketed under many names, including FLEXIJOINT, FLEXIPURE, MOVE FREE, OSTEO BI-FLEX, and TRIPLE FLEX.

Most studies testing the effectiveness of this product were small, were not well designed and showed conflicting results. However, in 2006, researchers funded by the National Institutes of Health published a large, controlled clinical study — known as the GAIT study — enrolling over 1,500 participants with knee osteoarthritis.[29] The study was double-blinded, meaning neither the researchers nor the subjects knew which subjects received glucosamine and/or chondroitin and which received placebo, eliminating the possibility that a researcher’s or patient’s expectations about treatment could bias the results.

This study found that after one year, neither glucosamine nor chondroitin, nor a combination of the two, taken for 24 weeks was more effective than a placebo at relieving osteoarthritic knee pain.[30]

A smaller group of 72 GAIT study participants who had moderate to severe pain and received both glucosamine and chondroitin did appear to experience a significant benefit relative to the 70 participants who received placebo. However, because of the small number of patients and the fact that this analysis was not part of the original study, the researchers could not rule out the possibility that this effect was due to random chance.[31]

A follow-up report on the GAIT study, published in 2010, showed that subjects with moderate to severe pain were no more likely to experience pain reduction than patients with mild pain after taking glucosamine and chondroitin for two years.[32]

While not effective, glucosamine and chondroitin have no serious side effects. Many physicians therefore do not object if patients continue to take these supplements.

It is hard to know whether the pain relief patients may experience while taking these supplements is due to the supplement itself, the body’s natural healing or a “placebo effect,” in which the patient’s expectations can influence his or her body’s response.

Advice for patients: Worst Pills, Best Pills News recommends against using glucosamine or chondroitin for osteoarthritis pain because they appear to be no more effective than placebo.

References

[1] National Institute for Health and Care Excellence. Osteoarthritis care and management in adults. Clinical guideline CG177. February 2014.

[2] Ibid.

[3] Juhl C, Christensen R, Roos EM, et al. Impact of exercise type and dose on pain and disability in knee osteoarthritis. Arthritis Rheumatol. 2014;66 (3):622-636.

[4] Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis. JAMA. 2013;310(12):1263-1273.

[5]Towheed T, Maxwell L, Judd M, et al. Acetaminophen for osteoarthritis (Review). Cochrane Collaboration. 2009.

[6] Ibid.

[7] Food and Drug Administration. FDA Approved Drug Products. Tylenol [package insert]. http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/019872Orig1s042lbl.pdf. Accessed May 6, 2015.

[8] Barkin RL, Beckerman M, Blum SL, et al. Should nonsteroidal anti- inflammatory drugs (NSAIDs) be prescribed to the older adult? Drugs Aging. 2010;27 (10):775-789

[9] Further evidence that Celebrex is a do not use drug; new designation of diclofenac (VOLTAREN) as a do not use drug; and other do not use NSAIDs. Worst Pills, Best Pills News. June 2014. /newsletters/view/905. Accessed April 21, 2015.

[10] Ibid.

[11] Agency for Healthcare Research and Quality. Analgesics for osteoarthritis: An update of the 2006 comparative effectiveness review. October 2011. AHRQ Publication No. 11(12)-EHC076-EF.

[12] Ibid.

[13] National Institute for Health and Care Excellence. Osteoarthritis care and management in adults. Clinical guideline CG177. February 2014.

[14] Ibid.

[15] Balmaceda CM. Clinical trial data in support of changing guidelines in osteoarthritis treatment. J Pain Res. 2014;7:211-218.

[16] Ibid.

[17] Ibid.

[18] National Institute for Health and Care Excellence. Osteoarthritis care and management in adults. Clinical guideline CG177. February 2014.

[19] Ibid.

[20] Food and Drug Administration. Topical pain relievers may cause burns. September 13, 2012. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm318674.htm. Accessed April 21, 2015.

[21] Ibid.

[22] WorstPills.org. Drug Profile: Celecoxib (CELEBREX), meloxicam (MOBIC), rofecoxib (VIOXX), valdecoxib (BEXTRA). Last reviewed August 31, 2014. /monographs/view/121. Accessed April 21, 2015.

[23] Ibid.

[24] Ibid.

[25] Agency for Healthcare Research and Quality. Analgesics for osteoarthritis: An update of the 2006 comparative effectiveness review. October 2011. AHRQ Publication No. 11(12)-EHC076-EF.

[26] National Institute for Health and Care Excellence. Osteoarthritis care and management in adults. Clinical guideline CG177. February 2014.

[27] Ibid.

[28] Dore RK. How to prevent glucocorticoid-induced osteoporosis. Cleve Clin J Med. 2010;77(8):529-36.

[29] Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006:23:354(8):795-808.

[30] National Center for Complementary and Integrative Health. Questions and answers: NIH glucosamine/chondroitin arthritis intervention trial primary study. Updated October 2008. https://nccih.nih.gov/research/results/gait/qa.htm. Accessed April 21, 2015.

[31] Ibid.

[32] Sawitzke AD, Shi H, Finco MF, et al. Clinical efficacy and safety over two years use of glucosamine, chondroitin sulfate, their combination, celecoxib or placebo taken to treat osteoarthritis of the knee: a GAIT report. Ann Rheum Dis. 2010;69(8):1459-1464. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086604/. Accessed April 21, 2015.