OTC Arthritis Treatment: Where Do We Stand?

Arthritis is a disabling disease that affects 66 million Americans and costs the US economy >$86.2 billion dollars annually.1 Recently, media coverage has been overwhelming consumers about the proper treatment of arthritis.

The Controversy

Questions about arthritis have been inundating community pharmacists since the removal of rofecoxib from the market in September 2004 and valdecoxib in April 2005. Recent studies have shown an increased risk of cardiovascular side effects or gastrointestinal (GI) bleeding with cyclooxygenase-2 (COX- 2) inhibitors and with the conventional nonsteroidal anti-inflammatory drugs (NSAIDs), including naproxen.

The Disease

Arthritis is a disabling disease noted for pain in 1 to multiple joints (arthro-) due to inflammation (-itis). With >100 specific forms of arthritis, the cause may be a single factor or multiple factors, including injury, wear and tear, infection, crystalline formation, tumor, and autoimmune disorders. The underlying pathophysiology is the deterioration of the natural joint cushion aggravated by inflammation. Depending on the cause, the type of presentation will vary.

Treatment Principles

OTC treatment of arthritis, especially any long-term treatments, should be sought only after an appropriate health care provider has diagnosed the patient. The most common type of arthritis about which patients will ask OTC questions will be osteoarthritis (OA). In many cases, other types will require prescription therapy for effective treatment.

The best starting point is the use of nonpharmacologic measures. A burden to joints is the weight they carry, which can be dramatically decreased with dieting and exercise. Patients should pursue exercises that stabilize and strengthen the muscles at the joint (isometric), along with improving the range of motion. When general relief is needed, heat applications with hot water soaks or heating pads may be an option.

For patients who present with mild-to-moderate symptoms of OA, acetaminophen (APAP) would be a first-line recommendation. APAP lacks the antiinflammatory properties of NSAIDs but is a good analgesic for mild-to-moderate pain. To achieve maximum analgesic effect would require taking 325 to 650 mg every 4 to 6 hours, not to exceed 4000 mg per day. Pharmacists should be cautious about suggesting APAP to patients who drink heavy amounts of alcohol or have hepatic disease.

Aspirin (ASA) has an analgesic effect roughly equivalent to that of APAP, when dosed at 325 to 650 mg every 4 to 6 hours, and not exceeding 4000 mg per day. To achieve any anti-inflammatory effect from ASA would require higher doses and thus would produce a higher risk of complications. Pharmacists should caution against chronic use of ASA at any of these higher doses.

Another analgesic found to be helpful is capsaicin, a red pepper extract, which depletes substance P, a neurotransmitter. The depletion of substance P results in decreased pain signals to the brain and therefore increased pain relief. Other counterirritants also may be used to provide temporary relief for up to 7 days at a time.

If the pain is not relieved with the above measures, or if the patient presents with moderate-to-severe pain, a trial with an NSAID may be appropriate. The American College of Rheumatology suggests NSAIDs as second-line agents for the treatment of OA. Most patients are likely to see an improvement in pain control while using an NSAID, compared with APAP.6 Although the pain control may be improved, increased risks are associated with their use. The risks of GI bleeding and renal failure are higher in patients with OA, because these patients usually are older and at greater risk for both of these events (Table 1).

Supplements

Natural remedies for the relief of pain associated with arthritis and other inflammatory conditions include, but are not limited to, herbal anti-inflammatory agents, homeopathy, systemic enzymes, glucosamine, chondroitin, omega-3 fatty acids, methyl sulfonyl methane, SAM-e, and colostrum (Table 2). A discussion of all of these supplements is beyond the scope of this article. (See also Natural Treatments for Osteoarthritis in this issue.)

Acknowledgment

The author would like to thank Whit Moose, Jr, RPh, and Stefanie Ferreri, PharmD, CDE, for their assistance with this article.

Dr. Bowman is a community pharmacy resident with the University of North Carolina at Chapel Hill School of Pharmacy and Moose Pharmacies.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: astahl@ascendmedia.com.