Nonprescription Analgesics and Self-management Strategies for Osteoarthritis

The arthritis foundation indicates that the degenerative joint disease osteoarthritis (OA) is the most prevalent form of arthritis, affecting more than 32.5 million adults in the United States and more than 7% of the world population, representing more than 500 million individuals globally.^1,2 According to the Global Burden of Disease Study 2019, OA is an ongoing public health concern, with projections continuing to increase due to the growing aging population and the ongoing obesity epidemic.³ OA is one of the primary causes of pain and disability worldwide.^1-5

The pathogenesis of OA can be due to genetic, metabolic, or environmental factors, with the most common risk factors for OA including older age, women aged 50 or older, being overweight or obese, joint overuse or injury, and musculoskeletal abnormalities.^1-5 Some individuals also have a genetic susceptibility to developing OA.^1-5

Although there is no cure for OA, there are numerous measures that patients can employ to alleviate and/or minimize pain and to improve mobility and overall health-related quality of life. OA most commonly affects the weight-bearing joints, including the knee and hip; OA can also affect the neck, lower back, feet, and hands.^1,5,6 OA symptoms typically develop gradually, and patients may present with an array of symptoms that may vary in degree of severity and clinical presentation. Some patients with OA may require support carrying out daily tasks such as climbing stairs, walking, lifting or grasping objects, and standing up from a seated position.⁶

Many individuals suffering from joint pain, stiffness, swelling, mobility issues, and sleep disturbances associated with OA often elect to use the various nonprescription oral and topical analgesics on the market. The pain associated with OA can be self-managed after a medical diagnosis is confirmed.⁶ The selection of therapy should be tailored to patient needs based on the patient’s symptoms, allergies, medical and medication history, and patient preferences.

Clinical interventions for treating and managing OA may involve nonpharmacological measures such as rest, ice, compression, and elevation (RICE); weight loss if needed; braces and support devices for affected joints; exercise; and physical therapy when appropriate. In some cases, health care providers may recommend heat therapy.⁶

Pharmacological therapies may include oral and topical analgesic formulations tailored to patient needs. Oral nonprescription analgesics include acetaminophen, aspirin, and nonsteroidal anti-inflammatory (NSAID) agents, including ibuprofen and naproxen. In 2020, the FDA approved the first combination of ibuprofen and acetaminophen as an OTC analgesic that contains acetaminophen 250 mg and ibuprofen 125 mg in each caplet in a single dose.⁷

Nonprescription topical analgesic products are available as gels, sprays, ointments, creams, lotions, and patches, which may contain menthol, camphor, capsaicin, trolamine salicylate, lidocaine, diclofenac sodium, and methyl salicylate.⁶ In February 2020, the FDA reclassified topical diclofenac sodium gel 1% from prescription status to OTC status for the temporary relief of OA pain, marking the first and only topical NSAID as an OTC product.⁶ Topical analgesic formulations are available as either a single entity or combination product and can be classified as having local analgesic, anesthetic, antipruritic, and/or counterirritant effects.⁶

According to the 2019 American College of Rheumatology/Arthritis Foundation (ACR/AF) Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee, treatment decisions should be based on shared decision-making between the clinician and patient while considering the patient’s values, preferences, and medication and medical history.⁸ Treatment should entail educational, behavioral, psychosocial, and physical interventions. The ACR/AF guideline indicates that when no contraindications are present, oral NSAIDs are strongly recommended for patients with knee, hip, and/or hand OA, and acetaminophen is conditionally recommended for knee, hip, and/or hand OA.⁸ The guideline also indicates that exercise is strongly recommended for knee, hip, and/or hand OA, and topical NSAIDs are strongly recommended for patients with knee OA and conditionally recommended for hand OA.⁸ Topical capsaicin is conditionally recommended for knee OA and conditionally recommended against in patients with hand OA.⁸

Pharmacists can be instrumental in assessing the appropriateness of self-treatment, screening for possible drug-drug interactions and contraindications, and encouraging patients to seek medical advice from their primary health care provider to confirm the diagnosis of OA so that the proper therapy can be promptly initiated.

Recent News and Clinical Studies

Researchers at Stanford University School of Medicine conducted a retrospective cohort study to ascertain the incidence of OA in patients with atopic disease (AD) compared with individuals without AD. In this study, the researchers focused on asthma and eczema. The findings, which were published in Annals of Rheumatic Diseases,revealed that over 10 years, patients with asthma or eczema had a 58% augmented risk of developing OA. Additionally, patients with asthma had an 83% augmented risk of developing OA compared with patients with COPD.9,10 The risk of developing OA increased to 115% if the patient had both asthma and eczema.^9,10

“Our findings provide the foundation for future interventional studies that could identify the first treatment to reduce the progression of osteoarthritis,” said lead author Matthew C. Baker, MD, MS, an assistant professor of immunology and rheumatology, in a press release.¹⁰

According to study data presented at the 2023 World Congress on Osteoarthritis, early initiation of exercise in those with knee OA—even within their first year of pain or decreased function—is linked with modestly lower pain scores and better function compared with individuals whose symptoms have lasted longer.11

Findings in a recent publication in JAMA Network Openshowed that among patients with type 2 diabetes who were using metformin, there was a 24% lower risk of developing OA than in individuals receiving sulfonylurea treatment.¹² The authors indicated that their findings further support preclinical and observational data that suggest the use of metformin may have protective properties that may diminish the risk of OA; however, additional studies are warranted.¹²

Conclusion

Left undiagnosed and untreated, OA can significantly affect an individual’s productivity and health-related quality of life. As frontline health care providers, pharmacists can be instrumental in identifying patients at risk for and/or exhibiting signs of OA. They can also encourage these patients to seek further medical evaluation to ascertain the appropriate treatment plan and to determine if self-treatment is appropriate.

Prior to advocating the use of any of these agents, pharmacists should always review a patient’s medical history and current drug profile and screen for drug-drug interactions and/or contraindications. Pharmacists can also ensure that patients understand the proper use of the selected OTC product, including dosage, recommended duration of use, and potential adverse effects. Clinical interventions from pharmacists provide patients with pertinent information to make informed decisions regarding the optimal treatment for OA pain and promote the safe and proper use of selected therapies for OA.

References

1. Osteoarthritis. Arthritis Foundation. Accessed May 9, 2023. https://www.arthritis.org/diseases/osteoarthritis
2. Hunter DJ, March L, Chew M. Osteoarthritis in 2020 and beyond: a Lancet Commission. Lancet. 2020;396(10264):1711-1712. doi:10.1016/S0140-6736(20)32230-3. Epub 2020 Nov 4. PMID: 33159851.
3. Long H, Liu Q, Yin H, Wang K, Diao N, Zhang Y, et al. Prevalence trends of site-specific osteoarthritis from 1990 to 2019: findings from the global burden of disease study 2019. Arthritis Rheumatol. 2022;74(7):1172-1183. doi:10.1002/art.42089. Epub 2022 Jun 2. PMID: 35233975; PMCID: PMC9543105.
4. He Y, Li Z, Alexander PG, Ocasio-Nieves BD, Yocum L, Lin H, et al. Pathogenesis of osteoarthritis: risk factors, regulatory pathways in chondrocytes, and experimental models. Biology (Basel). 2020;9(8):194. doi:10.3390/biology9080194. PMID: 32751156; PMCID: PMC7464998.
5. Osteoarthritis. Centers for Disease Control and Prevention. Updated July 27, 2020. Accessed May 9, 2023. https://www.cdc.gov/arthritis/basics/osteoarthritis.htm
6. Olenak J, Pezzino N. Musculoskeletal injuries and disorders. In: Krinsky DL, Ferreri SP, Hemstreet BA, Hume AL, Newton GDHume AL, Rollins CJ, Tietze KJ, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 20th ed. American Pharmacists Association; . November 20, 2020.
7. FDA approves GSK’s Advil Dual Action with Acetaminophen for over-the-counter use in the United States. News release. GlaxoSmithKline. March 2, 2020. Accessed May 9, 2023. https://us.gsk.com/en-us/media/press-releases/fda-approves-gsk-s-advil-dual-action-with-acetaminophen-for-over-the-counter-use-in-the-united-states/
8. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2020;72(2):149-162. doi:10.1002/acr.24131. Epub 2020 Jan 6.
9. Baker MC, Sheth K, Lu R, Lu D, von Kaeppler EP, Bhat A, et al. Increased risk of osteoarthritis in patients with atopic disease. Ann Rheum Dis. 2023;82(6):866-872.3:ard-2022-223640. doi:10.1136/ard-2022-223640. Epub ahead of print. PMID: 36987654.
10. Moskal E. Asthma, eczema are associated with higher risk of osteoarthritis, Stanford-led research finds. Stanford Medicine. March 27, 2023. Accessed May 24, 2023. https://med.stanford.edu/news/all-news/2023/03/osteoarthritis-asthma-eczema.html
11. Haelle T. Early exercise intervention improves knee osteoarthritis. MDedge Rheumatology. March 20, 2023. Accessed May 9, 2023. https://www.mdedge.com/rheumatology/article/261887/osteoarthritis/early-exercise-intervention-improves-knee-osteoarthritis
12. Baker MC, Sheth K, Liu Y, Lu D, Lu R, Robinson WH. Development of osteoarthritis in adults with type 2 diabetes treated with metformin vs a sulfonylurea. JAMA Netw Open. 2023;6(3):e233646. doi:10.1001/jamanetworkopen.2023.3646

About the Author

Yvette C. Terrie, BS Pharm, RPh, is a consulting pharmacist and medical writer in Haymarket, Virginia.