Joint Pain

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

Arthralgia, commonly referred to asjoint pain, can be the result of bothinjuries and various medical conditionsand is commonly characterized bysymptoms of stiffness, swelling, limitationof motion, weakness, and fatigue.¹According to statistics from the Centersfor Disease Control and Prevention(CDC), in 2006, an estimated 30% ofadult individuals reported experiencingsome type of joint pain during thepreceding 30 days. In addition, 18% ofrespondents reported knee pain, 9%reported shoulder pain, 7% reportedjoint pain in fingers, and 7% reportedhip pain.² Joint pain can be caused byosteoarthritis (OA), various types ofinjuries, prolonged abnormal posture,or repetitive motion.²

OA and rheumatoid arthritis are 2 ofthe most prevalent causes of joint pain.Other medical conditions that can causejoint pain include gouty arthritis, lupus,bursitis, tendonitis, and osteomyelitis.^3,4In addition, examples of other possiblecontributors to joint pain include excessweight, increasing age, genetic defectsin joint cartilage, sedentary lifestyle, andstress on the joint from certain sportsactivities or occupations.^3,4 Only the painassociated with OA is approved for self-treatmentafter an initial medical diagnosishas been established.⁵ Statisticsfrom the Arthritis Foundation reportthat an estimated 27 million individualsin the United States have some degreeof OA.^6,7 Whereas OA can occur in anyjoint, the condition most often affectsthe weight-bearing joints of the hips,knees, and lower back. It also can affectthe neck, small finger joints, the base ofthe thumb, and the big toe.^3,6

In general, the goals for treating OAinclude improving an individual's qualityof life by providing pain relief andenhancing joint mobility. Selection oftreatment is dependent upon variousfactors, including severity of the OA,the patient's medical history, currentmedication profile, and allergy history.After these factors are evaluated forpotential contraindications, the electedtherapy may include one or more of thefollowing: systemic and topical pharmacologicagents, physical therapy, rest,heat and cold therapy, weight loss, theuse of devices to take strain off of joints,such as canes and splints, and surgery,when warranted. OTC analgesics suchas nonsteroidal anti-inflammatory drugs(NSAIDs) and acetaminophen are commonlyused in the treatment of OA.Acetaminophen, when compared withNSAIDs, is considered to be the drugof choice for the treatment of OA wheninflammation is not a chief concernbecause of its reduced adverse effectprofile.⁵ NSAIDs are the preferred drugsof choice, however, when inflammationalso is present and no potentialcontraindications or drug interactionsare present.⁵

Topical Therapies

Topical products used for treating jointpain can be used in conjunction withsystemic agents or as the sole therapy ofchoice. They may contain one or moreof the following ingredients: methylsalicylate, camphor, menthol, methylnicotinate, capsaicin, or trolamine salicylate,and are available as gels, ointments,creams, lotions, and patches.Patients should be advised to apply topicalproducts only to skin that is intactand should not cover areas treated withcounterirritants with tight bandages orocclusive dressing.⁵ Patients also shouldbe advised not to use heating deviceswith topical counterirritants.⁵ Topicalpatches for treating joint pain are availablein various sizes that provide 8 to 12hours of continual heat therapy.

Dietary Supplements

Also available for the treatment of jointpain are various dietary supplements,such as glucosamine, chondroitin sulfate,methylsulfonylmethane (MSM),and S-adenosyl-L-methionine (SAMe).These supplements are availableas either single-entity or combinationproducts. Studies have shown that glucosaminesulfate not only reduces thepain associated with OA but may alsoslow down the progression of the disease.⁸

Glucosamine is an endogenous mucopolysaccharideused in the synthesis ofcartilage.^9,10 The most common adverseeffects of glucosamine include mild gastrointestinalupset, nausea, heartburn,and diarrhea, which can be alleviated ifit is taken in divided doses with meals.¹⁰Glucosamine should not be used if anindividual is allergic to shellfish. Patientswith diabetes should be aware of the possibility of hyperglycemiawhen using glucosamine and should be advised todiscuss the use of this product with their physician prior touse.¹⁰ Chondroitin sulfate is a glycosaminoglycan made fromglucuronic acid and galactosamine present in animal cartilageand helps cartilage retain water.^10,11

MSM also has been added to many of the glucosamine/chondroitin supplement products. MSM is a sulfur source thatis released on breakdown by intestinal bacteria.¹⁰ Althoughits exact mechanism of action with regard to OA is unclear,MSM has an essential role in maintaining the elasticity andflexibility of the connective tissue that makes up joints.^11,12Patients should be advised that these supplements will notprovide pain relief as quickly as NSAIDs or acetaminophen,and their therapeutic effects may not be evident for severalweeks or months.¹⁰

SAM-e is produced primarily in the liver.¹⁰ It is best knownand marketed as a mood stabilizer. Both liver disease and lowlevels of vitamin B₁₂ and folate may reduce SAM-e levels.¹⁰SAM-e should not be used in conjunction with antidepressantsand 5-HT₁ agonists because of an increased risk of serotoninsyndrome.¹⁰

More information on these supplements can be foundat the National Institutes of Health's National Center forComplementary and Alternative Medicine Web site at nccam.nih.gov.

The Role of the Pharmacist

Prior to recommending any of these OTC products, pharmacistsshould always assess the appropriateness of selftreatmentby evaluating the patient's symptoms, review thepatient's medical history, drug profile, and allergy history, andscreen for drug?drug interactions and possible contraindicationsassociated with the use of these products. Furthermore,pharmacists should remind patients currently taking anyother medications, those with preexisting conditions, andwomen who are pregnant or lactating to always consult aphysician before using any of these products. Key points toaddress during counseling include the proper use (dosageand administration guidelines) of these products, as well aspotential adverse effects. Pharmacists also can make recommendationsabout nonpharmacologic measures that patientsmay incorporate into their treatment regimen to help alleviatejoint pain. Patients with severe and continual (or worsening)joint pain should be encouraged to seek further evaluation andtreatment from their primary health care provider, when warranted.⁵ For more information regarding OA and its treatmentand management, please visit the following Web sites:

• Arthritis Foundation Web site: www.arthritis.org.
• National Institute of Arthritis and Musculoskeletal and Skin Diseases Web site: www.niams.nih.gov.
• CDC Web site: www.cdc.gov.

Table

Examples of OTC Products for Joint Pain

Systemic Analgesic Products

? Arthriten Maximum Strength Coated Tablets

? Advil Tablets/Caplets

? Bayer Extra Strength Back & Body Pain

? BC Arthritis Strength Pain Reliever/Fever Reducer, Powders

? Ecotrin Arthritis Relief Maximum Strength

? Motrin

? Tylenol Arthritis Pain Extended Release Pain Reliever Caplets

Topical Products For Joint Pain

? ActivOn Topical Analgesic, Ultra Strength Joint & Muscle

? Arthritis Hot Deep Penetrating Pain Relief Cream

? Aspercreme Nighttime Arthritis Pain Relieving Lotion

? Bengay Arthritis Formula Pain Relieving Cream

? Blu Stop Pain Relieving Gel

? Capzasin Arthritis Pain Relief

? Castiva Arthritis Pain Relief Lotion

? Cura-Heat Penetrating Pain Relief, Arthritis

? IcyHot PM Medicated Lotion

? Mobisyl Maximum Strength Arthritis Pain Relieving Creme with Aloe Vera

? MyoRx Arthritis and Muscle Pain with Omega Oils Cream

? Natrol MSM with Glucosamine Topical Creme

? ThermaCare Arthritis HeatWraps

? Tiger Balm Arthritis Rub

? Ultra Blue Topical Analgesic Gel Pain Reliever with MSM and Emu Oil

? WellPatch Arthritis Relief

? Zostrix Triple Strength Formula Arthritis Pain Relief Topical Analgesic Cream

Dietary Supplements

? Cosamin DS Joint Health Supplement

? Cosamin MSM

? Flex-A-Min Glucosamine Chondroitin MSM, Triple Strength

? Inholtra Premium Lubri-Joint Gel Caps

? Nature Made Glucosamine Tablets

? Nature Made Triple Flex Bone & Joint Caplets

? Nature's Way Glucosamine Sulfate MSM Tablets

? Osteo Bi-Flex Double and Triple Strength Glucosamine Chondroitin with MSM and Joint Shield Coated Caplets

? RenewIn Joint Care Tablets

? Schiff Move Free Advanced Triple Strength

? Schiff Move Free Advanced Triple Strength Plus MSM and Vitamin D

? Schiff Move Free Advanced plus MSM

Homeopathic Products

? Hyland's Arthritic Pain Formula Natural Relief Tablets

? Boiron Arthritis Pain Relief Tablets

? NatraBio Arnica Relief Tablets

References

• Baer A, Patel V, McCormack R. The approach to the painful joint. Emedicine Web site. www.emedicine.com/med/topic3562.htm. Accessed December 11, 2008.
• QuickStats: percentage of adults reporting joint pain or stiffness—national health interview survey, United States, 2006. MMWR Morb Mortal Wkly Rep. Centers for Disease Control and Prevention Web site. www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a9.htm. Accessed December 11, 2008.
• Arthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Web site. www.niams.nih.gov/Health_Info/Osteoarthritis/osteoarthritis_ff.asp. Accessed December 11, 2008.
• Joint Pain. National Institutes of Health's Medlineplus Web site. www.nlm.nih.gov/medlineplus/ency/article/003261.htm. Accessed December 11, 2008.
• Wright E. Musculoskeletal Injuries and Disorders. In: Berardi RR, Kroon LA, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 15th ed. Washington, DC: American Pharmacists Association; 2006:111-129.
• Osteoarthritis. Arthritis Foundation Web site. www.arthritis.org/disease-center.php?disease_id=32. Accessed December 11, 2008.