Continuing Medical Education: Understanding Osteoarthritis.

Medications

Can analgesics be prescribed for a person with osteoarthritis?

• Acetaminophen - Recent study found that 4000 mg of acetaminophen was as effective as 1200 mg of ibuprofen in OA. A definite consideration in all patients but especially in those with risk factors for NSAID toxicity. Can be added in prn doses to NSAIDs.
• Propoxyphene/Codeine - Can be used in patients without other options but in limited amounts. I usually give small monthly amount ie #15 and will not refill before the month is over. Avoid stronger, more potentially addictive opiates.
• Capsaicin Cream - Inhibits activity of substance P. Recent study of hand OA found reduction of pain by 40% and stiffness by 30% when applied QID for4 weeks at the 0.075% strength compared to placebo.
• Tricyclics - Several studies have demonstrated the usefulness of low dose TCAs in improving sleep and pain in patients with OA. It is always useful to address sleep quality as we may be able to provide an improvement in pain by improving sleep quality. Some of the pain reliving qualities may be on the basis of their effects on serotonin.

Can analgesics and antiinflammatories be prescribed for a person with osteoarthritis?

• NSAIDs - The mainstay of medication therapy for OA. May interfere with the production of cartilage proteoglycans and therefore may have an adverse effect on OA (controversial). Patients over age 60 at greater risk for NSAID toxicity. Nonacetylated salicylates may be useful in patients at risk for NSAID toxicity but need something stronger than acetominphen. Several different NSAIDs can be tried before one gives up on these. Remember that medications should only be part of the total program of treatment.
• Injectable Corticosteroids - Useful as an adjunct to overall program. Some patients have several months of benefit. Should not be used more than 3-4 times per year and no more than 10 injections total into any weight bearing joint. May work by inhibiting production IL-1 and its subsequent effect on the production of proteolytic enzymes.

Surgery for arthritis at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington

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