Arthritis and pain medication
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
Click here: Second Opinion Arthritis Treatment Kit
Dealing with pain may be the most difficult problem a patient with arthritis has to deal with. It is also a tremendous challenge for the rheumatologist.
The first step is making the diagnosis because each form of arthritis is treated differently.
Just as there are different types of arthritis, there are also different types of pain. For example inflammatory pain seen in rheumatoid arthritis is different from the mechanical pain found in osteoarthritis. And both are different from the central neurotransmitter dysfunctional pain seen in fibromyalgia.
Every patient needs a pain management plan. What works for one person may not work for someone else. And the first treatment may not work. A variety of different treatments may need to be used.
Pain is the body's way of letting a person know something is wrong. When the body is injured, nerves in the affected area transmit these signals to the brain.
Pain is a protective mechanism. For example, if one touches a hot stove, pain signals from the brain alert the person to pull their hand away.
This acute pain is different from the chronic pain seen with many types of arthritis.
Arthritis pain is caused by several factors, such as:
•Inflammation, the process that causes the redness and swelling in joints;
•Damage to joint tissues, which results from the disease process leading to mechanical pressure on the joints;
•Fatigue that results from the disease process, which can make magnify pain;
•Depression or stress, which results from limitations caused by the pain.
People react differently to pain. Some have high pain thresholds and others do not. Emotional and social factors also play a role in pain response.
Many people with arthritis have found that by learning and practicing pain management skills, they can reduce their pain.
Recognizing those factors that make pain worse is the first step to take. These need to be identified. For example, is it...
• Increased disease activity
• Excessive physical activity
• Too much focus on pain
Then, those factors that might relieve the pain also need to be discovered. Here are some...
• Guided imagery
• Oral medications
• Topical preparations
• Hot and cold treatments
The brain produces natural pain-relieving chemicals. These are called endorphins.
Different stimuli produce endorphins. One example is strong emotional triggers.
The body also produces endorphins in response to medicines. Other external pain control methods, such as heat and cold treatments, can stimulate the body to either release endorphins or block pain signals in other ways.
Obviously, there are many medications that also relieve pain.
Analgesics are an example of a medication designed to reduce pain. There are many types of analgesics. Some pain medications are actually combinations of drugs that work together to relieve pain. Some pain medications are available over-the-counter (without a prescription), such as acetaaminophen. Others require a prescription, such as the narcotics oxycodone, propoxyphene, and codeine. Narcotic pain relievers can be addictive.
Non-steroidal anti-inflammatory drugs (NSAIDs) are a group of drugs commonly used to treat arthritis because of their analgesic (pain-killing), anti-inflammatory, and antipyretic (fever-reducing) properties. The mechanism of action of NSAIDs is the inhibition of the enzyme cyclooxygenase, which catalyzes arachidonic acid to prostaglandins and leukotrienes. Arachidonic acid is released from membrane phospholipids as a response to inflammatory stimuli.
NSAIDs interfere with prostaglandin production by inhibiting cyclooxygenase.
More information about NSAIDS:
•Pain and inflammation sometimes occur in a circadian rhythm (daily rhythmic cycle based on a 24 hour interval). Therefore NSAIDs may be more effective at certain times.
•NSAIDs are divided into two groups: those with plasma (blood) half-lives less than 6 hours (i.e. aspirin, diclofenac, ibuprofen) and those with half-lives greater than 10 hours (i.e. diflunisal, piroxicam, and sulindac). Since it takes three to five half-lives to stabilize blood levels, NSAIDs with longer half-lives require a loading dose to be given (large dose given initially). The "half-life" is the time it takes a drug to go down to half of its initial level.
•Prostaglandins, which are inhibited by NSAIDs, function in the body to protect the stomach lining, promote clotting of the blood, regulate salt and fluid balance, and maintain blood flow to the kidneys when kidney function is reduced. By decreasing prostaglandins, NSAIDs can cause stomach irritation, bleeding, fluid retention, and decreased kidney function.
•Synovial fluid (joint fluid) concentrations are 60% of plasma concentrations regardless of type of NSAID or its half-life. Synovial fluid is mostly the site of action of NSAIDs.
•NSAIDs are 95% albumin (protein) bound. The unbound fraction of the NSAID is increased in patients with low albumin concentrations such as in active rheumatoid arthritis and the elderly. This may enhance toxicity.
•Since NSAIDs bind to plasma proteins they may be displaced by or may displace other plasma-bound drugs such as coumadin, methotrexate, digoxin, cyclosporine, oral antidiabetic agents, and sulfa drugs. This interaction can enhance either therapeutic or toxic effects of either drug.
••NSAID studies which have shown a variation in patient response.
•About 60% of patients will respond to any single NSAID. A trial period of two weeks should be given to see anti-inflammatory effectiveness. About 10% of rheumatoid arthritis patients will not respond to any NSAID.
•A study in the United Kingdom revealed ibuprofen as the lowest risk for causing serious upper gastrointestinal distress. Naproxen, indomethacin, and diclofenac were viewed as an intermediate risk. Azapropazone, and piroxicam had the highest risk.
•Antipyretic and anti-inflammatory effects of NSAIDs can mask the signs and symptoms of infection.
•Adverse effects of NSAIDs which can occur at any time include renal (kidney) failure, hepatic (liver) dysfunction, bleeding, and gastric (stomach) ulceration, as well as other potential toxicities.
•NSAIDs (particularly indomethacin) can interfere with the pharmacologic control of hypertension and cardiac failure in patients who take beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, or diuretics.
•Long-term use of NSAIDs may have a damaging effect on chondrocyte (cartilage) function.
All NSAIDS carry a small but significant risk of cardiovascular events such as heart attack and stroke. Because of this danger, there has been an increased use of topical NSAIDS as opposed to oral NSAIDS.
Glucocorticoids or corticosteroids have potent anti-inflammatory properties, and are used in a wide variety of inflammatory conditions such as arthritis, colitis, asthma, bronchitis, certain skin rashes, and allergic or inflammatory conditions of the nose and eyes. There are numerous preparations of corticosteroids including oral tablets, capsules, liquids, topical creams and gels, inhalers and eye drops, and injectable and intravenous solutions.
Dosage requirements of corticosteroids vary among individuals and the diseases being treated. In general, the lowest possible effective dose is used. Corticosteroids given in multiple doses throughout the day are more effective, but also more toxic, than if the same total dose is given once daily in the morning, or every other day.
Disease-Modifying Antirheumatic Drugs or DMARDs: While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain, they do not prevent joint destruction or deformity. For patients with aggressive forms of disease such as rheumatoid arthritis, medications other than NSAIDs and corticosteroids are needed. These "second-line" or "slow-acting" medicines (listed below) may take weeks to months to become effective. They are used for long periods of time. If effective, they can promote remission, thereby retarding the progression of joint destruction and deformity.
Hydroxychloroquine (Plaquenil) is used in the treatment of malaria. It is also used for the treatment of rheumatoid arthritis. Side effects include upset stomach, skin rashes, muscle weakness, and vision changes. Even though vision changes are rare, patients taking Plaquenil should be monitored by an eye doctor (opthalmologist).
Sulfasalazine (Azulfidine) is an oral medication traditionally used in the treatment of mild to moderately severe inflammatory bowel diseases, such as ulcerative colitis and Crohn's colitis. Azulfidine is used to treat rheumatoid arthritis in combination with anti-inflammatory medications. Azulfidine is generally well tolerated. Common side effects include rash and upset stomach. Because Azulfidine is made up of sulfa and salicylate compounds, it should be avoided by patients with known sulfa allergies.
Gold salts have been used to treat rheumatoid arthritis throughout most of this century. Gold is not used by many rheumatologists any longer.
Biologics are laser-targeted medications that act on specific areas of the immune system. Among these are the TNF-inhibitors (Enbrel, Humira, Cimzia, Remicade, Simponi), the IL-6 inhibitor (Actemra), the T-cell blocker (Orenceia), and the B cell depleter (Rituxan). Many other biologics are currently in the pipeline. The approach to a patient with inflammatory destructive arthritis is to use biologics as soon as possible to effect remission. These drugs do have potential side effects related to immune suppression and patients should be watched closely by an experienced rheumatologist.
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