Medications for Osteoarthritis (OA)


Introduction

Aches and pains can sometimes persist despite implementing consistent lifestyle changes. As discussed previously, there are numerous treatments for worn-out knees and hips which don’t require you to see a doctor. These include exercise, weight loss and external aids. If pain continues to affect your quality of life, however, you might consider consultation with a medical professional to discuss medical interventions.


Some medical interventions require a prescription, others do not. All have risks and benefits, which require consultation and monitoring by a doctor. Read on to learn more about osteoarthritis and the risks and benefits of medication.


What is osteoarthritis (OA)?

OA is a common cause of pain and altered joint function in adults.(1) The knee is the most common joint affected.(2) OA was previously considered to be the result of ‘wear and tear’, but current research suggests that underlying inflammation affects all components of the joint, including joint surface cartilage, nearby bone, the joint capsule and surrounding soft tissues.(3) Damage to the joint organ manifests as worsening pain, tenderness, reduced range of motion, bony swelling, joint deformity and instability.(4) Fortunately, lifestyle changes, such as weight loss, exercise and external aids can improve joint pain and function. In some cases, additional medical treatment is required to reduce symptoms from OA.


Medications for OA

It is important to note that medication works best in conjunction with lifestyle measures.(5) Medications for OA are often used to increase mobility and reduce pain, so that patients can maintain active, healthy lifestyles. Medications do not treat the disease itself, but instead help you to manage the symptoms of OA. The below section discusses the benefits, risks and recommended use of a number of common medications and dietary supplements.


Topical anti-inflammatories

Inflammatory chemicals produced by your body cause pain, redness, swelling, heat and loss of function. Anti-inflammatory medications, such as diclofenac and ketoprofen, reduce the production of a number of inflammatory chemicals, which in turn can reduce pain.(6) A large review found that three in five patients achieve a 50% improvement in pain when applying an anti-inflammatory gel over knee and hand joints affected by OA.(6) The anti-inflammatory gel performed better than a normal gel, which did not contain anti-inflammatory medication.(7) The anti-inflammatory gel also performed just as well as anti-inflammatory tablets.(6) The gel form does not have the same gut, kidney or heart side effects as the tablet form.(8)

Oral anti-inflammatories

Patients who do not improve with topical anti-inflammatories, or who have OA in multiple joints or in their hip may also trial anti-inflammatory tablets.(6) These tablets work in a broader fashion than the gel to reduce your body’s inflammation and pain from OA.(6, 9, 10) As there is a risk of gut, kidney and heart problems when on these tablets in the long term, a doctor should monitor patient suitability, dose, duration and side effects.(11-16)


Topical capsaicin

Capsaicin is derived from hot chilli peppers and seems to alleviate pain transmission in mild OA.(17, 18) Application of capsaicin gel at the site of knee pain was more effective than normal (non-capsaicin) gel in a number of small studies, with benefits lasting for 12 weeks.(18, 19) The most common side effect is a local burning sensation, which occurs in over half of patients, but improves with prolonged use. Topical capsaicin has no effect on the gut, kidneys or heart.(5, 19, 20)


Duloxetine

Some patients cannot take anti-inflammatory tablets due to medical conditions. Others do not respond to first-line medications for OA. These people may benefit from a type of antidepressant called duloxetine.(21) Duloxetine increases brain chemicals that can inhibit pain signals travelling from your joints. Several trials have revealed that duloxetine decreases pain intensity by 30 to 50%.(22) Duloxetine dose should be monitored closely by a doctor. Side effects include nausea, fatigue, constipation, dry mouth, diarrhoea, sleepiness and dizziness.(21)


Glucocorticoid (cortisone) injections

Glucocorticoid injections provide pain relief in OA but should not occur routinely. Some evidence suggests that glucocorticoid injections on a regular basis can increase the joint cartilage damage in OA.(23) This treatment may be suitable for patients in high levels of pain who are seeking short-term pain relief and who have not benefited from other treatments.(24) Pain relief from a glucocorticoid injection seems to last for six weeks and then subsides.(25, 26) One trial suggested that exercise was more effective at reducing pain in knee OA than glucocorticoid injections.(27)


Paracetamol

Paracetamol does not seem to reduce pain in OA and so is not recommended as an initial treatment of knee or hip OA.(20) It also has similar side effects to other anti-inflammatory medications.(28)


Hyaluronic acid injections

Studies about hyaluronic acid injections in knee and hip OA do not show a major benefit.(29, 30) More studies are needed in this area before these injections can be recommended.(5) Large, rigorous trials have failed to demonstrate a relevant benefit of hyaluronic acid injections in OA.(31)

Platelet-rich plasma (PRP)

There is a growing body of evidence supporting PRP over saline (non-medication) and hyaluronic acid injections in OA. PRP is a blood product produced by centrifugation (spinning blood tubes) and removing the red blood cells from the mixture. One trial found that PRP reduces pain and increases function for 12 months in patients with knee OA.(32) PRP provides high concentrations of your body’s natural growth factors to the site of injections, which can increase cell division and cartilage healing in OA-affected joints.(33) PRP also seems to reduce inflammation in the joint.(34) Moreover, very few side effects are reported from PRP treatment.(35)


Opioids

Opioids, such as oxycodone, hydromorphone and tramadol, should only be used in the short term for severe OA symptoms that drastically impact your function.(5, 36) They are not beneficial long term and commonly cause nausea, dizziness and drowsiness.(37) Several studies have shown that opioids reduce pain by a level similar to anti-inflammatories.(38, 39)

Curcumin

There is some evidence that supplements containing curcumin, a component of turmeric, provide symptomatic relief with no side effects.(40)


Boswellia serrata

There is some evidence that Boswellia serrata, also known as Indian frankincense, provides symptomatic relief with no side effects.(40)


Other nutritional supplements

The supplements listed below require more studies to elucidate any benefit in OA. Some also require further research into safety and side effects: (5, 40-43)

  • Glucosamine (44-46)

  • Chondroitin (47, 48)

  • Vitamin D (49)

  • Diacerein

  • Avocado soybean unsaponifiables

  • Fish oil (50)

  • Phyto-flavonoids, including flavocoxid (51, 52)


Recommendations

At Surecell, we recommend trying a variety of lifestyle measures to manage your OA. Following adherence to lifestyle changes, patients may benefit from a discussion about medication options.


Support available at Surecell

If you are looking for tailored lifestyle and medication advice, we offer exercise physiology, personal training and gym facilities, as well as medical support. Surecell is a specialist provider of regenerative medicine treatments, including platelet-rich plasma (PRP). Feel free to contact our friendly staff on 03 9822 9996, or simply fill in your contact information here.


References

  1. Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatr Med. 2010;26(3):355-69.

  2. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163-96.

  3. Loeser RF, Goldring SR, Scanzello CR, Goldring MB. Osteoarthritis: a disease of the joint as an organ. Arthritis Rheum. 2012;64(6):1697-707.

  4. Zhang W, Doherty M, Peat G, Bierma-Zeinstra MA, Arden NK, Bresnihan B, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis. 2010;69(3):483-9.

  5. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363-88.

  6. Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016;4:CD007400.

  7. Roth SH, Fuller P. Diclofenac topical solution compared with oral diclofenac: a pooled safety analysis. J Pain Res. 2011;4:159-67.

  8. Kienzler JL, Gold M, Nollevaux F. Systemic bioavailability of topical diclofenac sodium gel 1% versus oral diclofenac sodium in healthy volunteers. J Clin Pharmacol. 2010;50(1):50-61.

  9. Caughey GE, Cleland LG, Penglis PS, Gamble JR, James MJ. Roles of cyclooxygenase (COX)-1 and COX-2 in prostanoid production by human endothelial cells: selective up-regulation of prostacyclin synthesis by COX-2. J Immunol. 2001;167(5):2831-8.

  10. Cheng Y, Austin SC, Rocca B, Koller BH, Coffman TM, Grosser T, et al. Role of prostacyclin in the cardiovascular response to thromboxane A2. Science. 2002;296(5567):539-41.

  11. Andersohn F, Suissa S, Garbe E. Use of first- and second-generation cyclooxygenase-2-selective nonsteroidal antiinflammatory drugs and risk of acute myocardial infarction. Circulation. 2006;113(16):1950-7.

  12. Chan AT, Manson JE, Albert CM, Chae CU, Rexrode KM, Curhan GC, et al. Nonsteroidal antiinflammatory drugs, acetaminophen, and the risk of cardiovascular events. Circulation. 2006;113(12):1578-87.

  13. Kearney PM, Baigent C, Godwin J, Halls H, Emberson JR, Patrono C. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ. 2006;332(7553):1302-8.

  14. McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase 2. JAMA. 2006;296(13):1633-44.

  15. Trelle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ. 2011;342:c7086.

  16. van Oijen MG, Dieleman JP, Laheij RJ, Sturkenboom MC, Jansen JB, Verheugt FW. Peptic ulcerations are related to systemic rather than local effects of low-dose aspirin. Clin Gastroenterol Hepatol. 2008;6(3):309-13.

  17. Anand P, Bley K. Topical capsaicin for pain management: therapeutic potential and mechanisms of action of the new high-concentration capsaicin 8% patch. Br J Anaesth. 2011;107(4):490-502.

  18. Deal CL, Schnitzer TJ, Lipstein E, Seibold JR, Stevens RM, Levy MD, et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther. 1991;13(3):383-95.

  19. Altman RD, Aven A, Holmburg CE, Pfeifer LM, Sack M, Young GT. Capsaicin cream 0.025% as Monotherapy for Osteoarthritis: A double-blind study. Seminars in Arthritis and Rheumatism. 1994;23(6):25-33.

  20. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578-89.

  21. Frakes EP, Risser RC, Ball TD, Hochberg MC, Wohlreich MM. Duloxetine added to oral nonsteroidal anti-inflammatory drugs for treatment of knee pain due to osteoarthritis: results of a randomized, double-blind, placebo-controlled trial. Curr Med Res Opin. 2011;27(12):2361-72.

  22. Wang ZY, Shi SY, Li SJ, Chen F, Chen H, Lin HZ, et al. Efficacy and Safety of Duloxetine on Osteoarthritis Knee Pain: A Meta-Analysis of Randomized Controlled Trials. Pain Med. 2015;16(7):1373-85.

  23. McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017;317(19):1967-75.

  24. Maricar N, Callaghan MJ, Felson DT, O'Neill TW. Predictors of response to intra-articular steroid injections in knee osteoarthritis--a systematic review. Rheumatology (Oxford). 2013;52(6):1022-32.

  25. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2005(2):CD005328.

  26. Juni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015(10):CD005328.

  27. Deyle GD, Allen CS, Allison SC, Gill NW, Hando BR, Petersen EJ, et al. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. N Engl J Med. 2020;382(15):1420-9.

  28. Roberts E, Delgado Nunes V, Buckner S, Latchem S, Constanti M, Miller P, et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis. 2016;75(3):552-9.

  29. Hunter DJ, Jarcho JA. Viscosupplementation for Osteoarthritis of the Knee. N Engl J Med. 2015;372(11):1040-7.

  30. Jevsevar D, Donnelly P, Brown GA, Cummins DS. Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review of the Evidence. J Bone Joint Surg Am. 2015;97(24):2047-60.

  31. Rutjes AW, Juni P, da Costa BR, Trelle S, Nuesch E, Reichenbach S. Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis. Ann Intern Med. 2012;157(3):180-91.

  32. Meheux CJ, McCulloch PC, Lintner DM, Varner KE, Harris JD. Efficacy of Intra-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review. Arthroscopy. 2016;32(3):495-505.

  33. Andia I, Maffulli N. Platelet-rich plasma for managing pain and inflammation in osteoarthritis. Nat Rev Rheumatol. 2013;9(12):721-30.

  34. van Buul GM, Koevoet WL, Kops N, Bos PK, Verhaar JA, Weinans H, et al. Platelet-rich plasma releasate inhibits inflammatory processes in osteoarthritic chondrocytes. Am J Sports Med. 2011;39(11):2362-70.

  35. Kanchanatawan W, Arirachakaran A, Chaijenkij K, Prasathaporn N, Boonard M, Piyapittayanun P, et al. Short-term outcomes of platelet-rich plasma injection for treatment of osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. 2016;24(5):1665-77.

  36. Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64(4):465-74.

  37. Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872-82.

  38. da Costa BR, Nuesch E, Kasteler R, Husni E, Welch V, Rutjes AW, et al. Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2014(9):CD003115.

  39. Smith SR, Deshpande BR, Collins JE, Katz JN, Losina E. Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review. Osteoarthritis Cartilage. 2016;24(6):962-72.

  40. Liu X, Machado GC, Eyles JP, Ravi V, Hunter DJ. Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis. Br J Sports Med. 2018;52(3):167-75.

  41. Clegg DO, Reda DJ, Harris CL, Klein MA, O'Dell JR, Hooper MM, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354(8):795-808.

  42. Lopez HL. Nutritional interventions to prevent and treat osteoarthritis. Part II: focus on micronutrients and supportive nutraceuticals. Pm R. 2012;4(5 Suppl):S155-68.

  43. Roman-Blas JA, Castaneda S, Sanchez-Pernaute O, Largo R, Herrero-Beaumont G, Group CGCTS. Combined Treatment With Chondroitin Sulfate and Glucosamine Sulfate Shows No Superiority Over Placebo for Reduction of Joint Pain and Functional Impairment in Patients With Knee Osteoarthritis: A Six-Month Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Arthritis Rheumatol. 2017;69(1):77-85.

  44. Eriksen P, Bartels EM, Altman RD, Bliddal H, Juhl C, Christensen R. Risk of bias and brand explain the observed inconsistency in trials on glucosamine for symptomatic relief of osteoarthritis: a meta-analysis of placebo-controlled trials. Arthritis Care Res (Hoboken). 2014;66(12):1844-55.

  45. Runhaar J, Rozendaal RM, van Middelkoop M, Bijlsma HJW, Doherty M, Dziedzic KS, et al. Subgroup analyses of the effectiveness of oral glucosamine for knee and hip osteoarthritis: a systematic review and individual patient data meta-analysis from the OA trial bank. Ann Rheum Dis. 2017;76(11):1862-9.

  46. Wu D, Huang Y, Gu Y, Fan W. Efficacies of different preparations of glucosamine for the treatment of osteoarthritis: a meta-analysis of randomised, double-blind, placebo-controlled trials. Int J Clin Pract. 2013;67(6):585-94.

  47. Reichenbach S, Sterchi R, Scherer M, Trelle S, Burgi E, Burgi U, et al. Meta-analysis: chondroitin for osteoarthritis of the knee or hip. Ann Intern Med. 2007;146(8):580-90.

  48. Singh JA, Noorbaloochi S, MacDonald R, Maxwell LJ. Chondroitin for osteoarthritis. Cochrane Database Syst Rev. 2015;1:CD005614.

  49. Jin X, Jones G, Cicuttini F, Wluka A, Zhu Z, Han W, et al. Effect of Vitamin D Supplementation on Tibial Cartilage Volume and Knee Pain Among Patients With Symptomatic Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2016;315(10):1005-13.

  50. Hill CL, March LM, Aitken D, Lester SE, Battersby R, Hynes K, et al. Fish oil in knee osteoarthritis: a randomised clinical trial of low dose versus high dose. Ann Rheum Dis. 2016;75(1):23-9.

  51. Chalasani N, Vuppalanchi R, Navarro V, Fontana R, Bonkovsky H, Barnhart H, et al. Acute liver injury due to flavocoxid (Limbrel), a medical food for osteoarthritis: a case series. Ann Intern Med. 2012;156(12):857-60, W297-300.

  52. Levy RM, Saikovsky R, Shmidt E, Khokhlov A, Burnett BP. Flavocoxid is as effective as naproxen for managing the signs and symptoms of osteoarthritis of the knee in humans: a short-term randomized, double-blind pilot study. Nutr Res. 2009;29(5):298-304.


© 2020 by Surecell Clinic. All Rights Reserved.

  • Grey Facebook Icon
  • Grey YouTube Icon
  • Grey LinkedIn Icon